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Predictors of quality of life in children
PERE A. BORRAS
1
,2
, JOSEP VIDAL
1
, XAVIER PONSETI
1
, JAUME CANTALLOPS
1
, PERE
PALOU
1
1
Physical Activity and Sports Sciences Research Group, University of the Balearic Islands, Palma de Majorca,
Spain
2
Jonh Hancock Research Center on Physical Activity, Nutrition and Obesity Prevention, Tufts University, Boston,
MA. USA
ABSTRACT
Borras PA, Vidal J, Ponseti X, Cantallops J, Palou P. Predictors of quality of life in children.
J. Hum.
Sport Exerc.
Vol. 6, No. 4, pp. 649-656, 2011. The aim of this study was to explore the relationship
between Health related quality of life (HRQoL) in children reported by parents, cardiorespiratory fitness,
physical activity levels, screen time and body mass index of a population of 302 eleven and twelve
years old children. The objective was to investigate the relation of cardiorespiratory fitness with some
domains of quality of life to determine if fitness is a key factor rather than physical activity, to ensure
future quality of life in children, Child health and Illness Profile-Child Edition/Parent Repot Form (CHIP-
CE/PRF) was used to measure HRQoL, 20m shuttle run test, for fitness. SHAPES, Physical activity
module was used to measure weekly physical activity and screen time. Height and weight was reported
by parents. Results show a strong correlation with Fitness and HRQoL, and screen time with HRQoL,
but not with Physical activity. The findings of this study suggest that Fitness in children is a more
important predictor, than PA in disease prevention.
Key words
:
CARDIORESPIRATORY FITNESS,
SCREEN TIME, PHYSICAL ACTIVITY, BMI.
1
Corresponding author.
Crta. Valldemosa km. 7,5 (edif. Guillem Cifre). Universitat de les Illes Balears, 07122 Palma de
Majorca, Spain.
E-mail: pa-borras@uib.es
Submitted for publication October 2011
Accepted for publication December 2011
JOURNAL OF HUMAN SPORT & EXERCISE ISSN 1988-5202
© Faculty of Education. University of Alicante
doi:10.4100/jhse.2011.64.08
Original Article
Borras et al. / Predictors of quality of life in children
JOURNAL OF HUMAN SPORT & EXERCISE
INTRODUCTION
The evidence of the benefits of physical activity and cardiovascular fitness on the physical health and
quality of life is well documented. These benefits include a reduced risk of coronary heart disease,
hypertension, and type II diabetes (Ortega et al.,
2008
). Health related quality of life (HRQoL) is a
resource for adaptation and healthy growth. When HRQoL diminishes, a child is less likely to be able to
develop normally and mature into a healthy adult (Riley et al.,
2006
). The frequency, duration and
intensity of physical activity necessary to confer these various benefits in children remain the subject of
debate, although the general consensus is for children and youth to accumulate an average of at least
60 minutes per day and up to several hours of at least moderate intensity, and aerobic activities should
make up the majority of the physical activity (Jansen & Leblanc,
2010
). The majority of the evidences
for the psychological benefits on physical activity in children is based upon single physical activity
sessions or cross sectional (self-report) studies, there is a recognized need to consider the effect of
habitual physical activity on children’s quality of life (Parfit & Eston,
2005
). Previous studies have shown
that lifestyles are associated with mental and health status, as well as HRQoL in adults, but there is no
consensus about the effect of Physical activity on the different determinants of HRQoL in children
(Chen et al.,
2005
).
The negative effects of sedentary lifestyles on children’s health is also a source of concern, the
increasing prevalence of obesity among developed countries coincides with an increasing prevalence of
high screen time (defined as a combination of activities such a watching television or playing video
games (Anderson et al.,
2008
; Letherdale et al.,
2008
). The American academy of pediatrics
recommends that children’s screen time be limited to no more than 1 to 2 hours per day.
Social cognitive theory posits that sedentary behavior is influenced by personal beliefs, physical
characteristics, and other related behaviors (frequency or regular participation in physical activity).
Empirical research has demonstrated support for these relationships with respect to screen time
(Leatherdale & Wong,
2008
). TV viewing also predicts lower fitness, but not higher Body Mass Index
(Mota et al.,
2010
), this is an important finding because cardiorespiratory fitness (CRF) is one of the
most important targets in preventing childhood obesity. There is also evidence that a strong relationship
between PA levels and metabolic risk exists in children with low CRF (Ortega et al.,
2008
).
Physical fitness is nowadays considered one of the most important health markers, as well as a
predictor of morbidity and mortality for cardiovascular disease (Aires et al.,
2010
). Childhood and
adolescence are crucial periods of life and improvement in cardiorespiratory fitness seem to positively
affect depression status, and self-esteem, this improvement is required for an enhanced psychological
well-being. In this regard the literature about young people is rather scarce (Ortega et al.,
2008
).
The links between obesity and HRQoL have been less studied, and limited research exists linking youth
obesity to poorer youth HRQoL, it appears likely that increasing weight status has a moderate to strong
negative influence on HRQoL in pediatric populations, whereby decrements of in HRQoL are evident as
soon as BMI is above the healthy normal limits (Tsiros et al.,
2009
), youth overweight showed
significant positive association to adult HRQoL, however no associations have been found
between
youth PA and adult mental or physical HRQoL (Herman & Hopman,
2010
).
We analyzed the relationship between BMI, Physical activity, screen time, Cardiorespiratory fitness and
Health related quality of life in children of 11-12 years old in Majorca Island, Spain during the school
year 2008-2009. The aim of this study was to examine the correlations between different factors of
quality of life, with anthropometric measures, levels of physical activity, cardiorespiratory fitness and
sedentary behaviors in children.
Borras et al. / Predictors of quality of life in children
JOURNAL OF HUMAN SPORT & EXERCISE
MATERIAL AND METHODS
Participants and data collection
This was a cross sectional study that was carried out as a part of the SAFE project, a school based
global intervention to promote healthy habits in school age children in the Balearic Islands, west coast
of Spain. This study collects information on a group of 11-12 children about their levels of Physical
activity, Physical inactivity (screen time) and Physical fitness, as well as collects the information of the
Health related Quality of Life reported by their parents.
A group of the 11-12 years old (grades 5-6), participants from regional elementary schools were
selected (n=302; 151 boys and 151 girls). The data described in this study was collected between
March and April 2009. The children and their families received written information about purposes and
the content of the study. Before the study began all parents, teachers and managers of schools
approved the study protocol, and all parents signed an informed consent. The ethics committee from
the University of the Balearic Islands approved this study.
Table
1
, shows both average BMI in a percentile 75 compared to CDC grow charts, and average level
of physical activity and also a cardiorespiratory fitness average for this European population (Ruiz et al.,
2011
).
Table 1.
Descriptive data for boys and girls.
Variable
Boys (n=151)
Girls (n=151)
Mean
(SD)
Mean
(SD)
Age (y)
11.6
(1.01)
10.7
(3.1)
BMI (kg/m
-2
)
19.40
(3.1)
18.50
(2.9)
Physical Activity (Hr./Week)
10.94
(6.05)
8.56
(5.6)
Cardiorespiratory Fitness (beeps)
4.39
(2.1)
3.37
(1.57)
Assessment of health related quality of life
The Spanish version of the Child Health and Illness Profile-Child Edition /Parent Report Form (CHIP-
CE/PRF) (Estrada et al.,
2010
) was used to evaluate Health related Quality of Life. This instrument
(Riley et al.,
2004
) collects parent reported health information about children aged 6-12 years. The
CHIP is based on a broadly defined conceptual framework which recognizes that health includes not
only perceptions of well-being, illness and health, but also participation developmentally appropriated
tasks and activities, originally this instrument include 5 domains, in this study we have used four
domains to shorten the time of the questionnaire (this version has been also validated); Satisfaction
with health, Physical comfort, Emotional comfort and restricted activity.
Assessment of physical activity and screen time
The School Health Action, Planning and Evaluation System (SHAPES) physical activity questionnaire
(Wong et al.,
2006
), consists of 45 multiple choice questions, items request 7 day recall of moderate to
vigorous PA, but not only to measure self-reported physical activity levels but inform about participation
in physical activities, sedentary activities (Watching TV, playing videogames, homework), social
influences (e.g., parent and peer influences), and school environment for children 11-16 years old.
Borras et al. / Predictors of quality of life in children
JOURNAL OF HUMAN SPORT & EXERCISE
Assessment of cardiorespiratory fitness
20m shuttle run test (20mSRT) from the ALPHA Health related fitness test battery for children and
adolescents, (Ruiz et al.,
2011
) recently validated and can be considered both valid and reliable to
assess cardiorespiratory fitness and seems to be the best one in estimate Vo2max in children and
adolescents.
Statistical analysis
Descriptive statistics (means and standard deviations) were calculated for all anthropometric
characteristics physical fitness, physical activity and sedentary behaviors (screen time) according to
gender group. Our analysis focused specifically on the association between HRQoL domains and
Physical activity levels, BMI, Screen time, CRF (Pearson correlation). On a secondary analysis we
focused in association between HRQoL domains and peer and parents physical activity influence,
Pearson correlation was used. The level of significance was set at p<0.05* and p<0.01**. Data were
analyzed using SPSS (Mac version 19.0).
RESULTS
Table
2
shows Pearson correlation between Health related quality of life domains (satisfaction physical
comfort, emotional comfort and restricted activity) with levels of physical activity, screen time,
cardiorespiratory fitness and BMI.
As a secondary analysis the influence of the active parents and active friends was an interesting field of
evaluation, Table
3
shows the relationship between the quality of life domains and peer and parents
influence.
As a consequence of the previous analysis cardiorespiratory fitness has emerged as a fundamental key
issue in quality of life, Table
4
shows Pearson correlations for CRF with Age, PA, Screen Time (ST),
BMI, and Active Friends.
Table 2.
Health related Quality of Life domains relationship with Physical Activity, Sedentary Behaviors,
Cardiorespiratory Fitness and Anthropometric measures.
Satisfaction
with health
Physical
comfort
Emotional
comfort
Restricted
activity
Physical
activity
Pearson
0.061
0.021
-0.019
-0.059
Sig.
0.291
0.717
0.740
0.312
N
301
301
299
298
Screen time
Pearson
-0.085
0.148*
0.109
0.191**
Sig.
0.143
0.010
0.061
0.001
N
301
301
299
298
CRFitness
Pearson
0.053
-0.127*
-0.077
-0.010
Sig.
0.367
0.029
0.190
0.861
N
293
293
291
290
BMI
Pearson
0.047
0.016
0.029
-0.127*
Sig.
0.415
0.785
0.623
0.028
N
301
301
299
298
BMI= Body Mass Index. CRFitness= Cardiorespiratory Fitness. p<0.05*; p<0.01**.
Borras et al. / Predictors of quality of life in children
JOURNAL OF HUMAN SPORT & EXERCISE
DISCUSSION
This study aimed to examine the relationship between quality of life domains reported by parents
through CHIP-CE/PRF with levels of physical activity, screen time, BMI, and cardiorespiratory fitness.
The analyzed group shows a BMI mean of 19.4 in boys and 18.5 in girls, according to CDC grow
charts, both boys and girls are at percentile 75, and according to Spanish consensus in measuring
weight and height (AEP, SENC, SEEDO), boys and girls are at percentile 70.
Physical activity pattern shown by our group is a little below the average for 11 years old children in
European population according to physical activity levels and patterns of 9-15 years old children in
Europe (Riddoch et al.,
2004
).
Table 3.
Pearson correlation for HRQoL domains and active peer and active parents influence.
Satisfaction
with health
Physical
comfort
Emotional
comfort
Restricted
activity
Active father
Pearson
-0.165**
0.098
0.090
0.102
Sig.
0.004
0.090
0.121
0.080
N
300
300
298
297
Active mother
Pearson
-0.074
0.107
0.090
0.077
Sig.
0.200
0.064
0.120
0.187
N
301
301
299
298
Active friends
Pearson
0.150**
-0.051
0.001
0.133*
Sig.
0.009
0.375
0.985
0.022
N
301
301
299
298
p<0.05*; p<0.01**.
Cardiorespiratory fitness in this group is in the percentile 50 for boys and percentile 55 for girls,
according to ALPHA norm values for physical fitness in European population (Ruiz et al.,
2011
).
Considering our focus group a standard population, we would like to analyze the relationship between
cardiorespiratory fitness with health related quality of life reported by parents.
The most important outcome of this study was the result showed that
cardiorespiratory fitness
predicts quality of life
(Physical comfort), so did it screen time (restricted activity), confirming the
findings that screen time is associated with sedentary behavior (Leatherdale et al.,
2010
).
BMI is associated with poor quality of life (restricted activity), on the contrary,
physical activity is not a
predictor for quality of life in children
. There is limited research linking HRQoL to physical activity in
children and Scarce literature linking Physical fitness to HRQoL, our research confirm the findings
about the BMI and physical activity associated with better or worse quality of life (Swallen et al.,
2005
),
who reported positive associations between BMI and HRQoL, and no associations were found between
Physical activity and HRQoL (Herman & Hopman,
2010
).
Borras et al. / Predictors of quality of life in children
JOURNAL OF HUMAN SPORT & EXERCISE
Table 4.
Cardiorespiratory Fitness correlation with analyzed variables.
Age
Physical
Activity
BMI
Screen Time
Active
Friends
CR-Fitness
Pearson
0.207**
0.175**
-0.241**
-0.130*
0.127*
Sig.
0.000
0.003
0.000
0.026
0.029
N
294
294
294
294
294
p<0.05*; p<0.01**.
Our findings confirm the hypothesis that Fitness has a positive association with HRQoL but no positive
associations to Physical activity. The key point, is the intensity of physical activity reported in the
questionnaires, Physical activity need a vigorous intensity to causes changes in fitness, and is in this
moment that affects the whole body not only affecting the energy balance but providing the subject
significant adaptations to their body.
On a deeper analysis on fitness, our findings suggest that better cardiorespiratory fitness is associated
with less screen time, confirming other studies that reported an inverse positive association between
screen time and cardiorespiratory fitness (Mota et al.,
2007
; Mota et al.,
2010
).
And last but not least, cardiorespiratory fitness is positively associated with physical activity and is also
positively associated with active friends, confirming results from studies relating environmental and peer
influences in physical activity and fitness (Leatherdale et al.,
2008
).
Analyzing the parent and peer influences, our findings show some associations with active friends and
HRQoL (satisfaction with health and restricted activity), the idea that quality of life includes not only
perceptions of well-being, illness and health, but also participation developmentally appropriated tasks
and activities, and the relations with relatives and friends.
The findings of this study are important due to many lifestyle habits are established during childhood,
physical activity and exercise habits may also be established during this years, but with an orientation
to improve Physical fitness, otherwise it will be a good activity to increase energy expenditure (Jakson
et al.,
2009
) but will not achieve the main objective, improving children’s health.
Strengths of this study are its original approach to the Health related quality of life from the Physical
fitness perspective, which allowed us to confirm the hypothesis that fitness is a powerful and relevant
marker of health. These findings are important because they provide a field of future research in the
relationship between physical fitness and HRQoL.
Limitations should be recognized. First the small sample size, and therefore results should be
interpreted with caution due to underpowered data. Self-report physical activity is also a limitation, but
results indicate similar PA levels to other studies with objective measures. In third place,
cardiorespiratory fitness were assessed indirectly although, 20m shuttle run test, is included in the
majority of fitness batteries around the world, and is considered a valuable tool for studying CRF in
young healthy children.
Borras et al. / Predictors of quality of life in children
JOURNAL OF HUMAN SPORT & EXERCISE
CONCLUSION
In conclusion, this study examined the association between HRQoL and CRF, PA, Screen time and
BMI, and the results suggest that Cardiorespiratory Fitness and Screen time have significant
association with some quality of life domains but not Physical activity.
ACKNOWLEDGMENT
This study was supported by grant: JC2010-245 from the Spanish Ministry of Education.
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