Prevalence and Factors Associated With Low Aerobic

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Prevalence and Factors Associated With Low Aerobic Performance Levels in Adolescents: A Systematic Review Eliane Cristina de Andrade Gonçalves, Diego Augusto Santos Silva* and Heloyse Elaine Gimenes Nunes Federal University of Santa Catarina. Post Graduate Program of Physical Education. Florianopolis, SC, Brazil Abstract: Low aerobic performance levels have been considered one of the risk factors for premature mortality, regardless of presence of other health problems. The critical analysis of studies on the prevalence of low aerobic performance and associated factors may contribute to the epidemiological knowledge and analysis / discussion of socio-cultural aspects that influence low aerobic performance. The aim of this systematic review was to identify studies on the prevalence of low aerobic performance levels and possible associations between low aerobic performance and demographic / biological D.A.S. Silva factors, lifestyle and excess body fat in adolescents (11-19 years). The search was conducted in PubMed and SciELO databases using descriptors "aerobic capacity" or "aerobic fitness", "cardiorespiratory capacity" or "cardiorespiratory fitness", "aerobic power" or "aerobic endurance" or "cardiorespiratory endurance" and "adolescents". After the search and exclusion criteria, 33 articles were selected. Factors that were associated with low aerobic performance levels were female gender, low income, low consumption of dairy products and / or bread / cereals, increased consumption of sweetened beverages, insufficient physical activity level, excessive screen time and excess body fat. The heterogeneity of factors related to low aerobic performance levels demonstrates the complexity of this topic and the need for further studies to obtain definitive conclusions.

Keywords: Adolescents, association, exercise, health, oxygen uptake, risk factors. INTRODUCTION The aerobic performance is an important health marker from childhood and adolescence [1]. It is described as the ability to deliver oxygen to muscles and use it to generate energy during physical exercises. Therefore, it depends on pulmonary, cardiovascular and hematological components of oxygen delivery and oxidative mechanisms of the exercising muscle [1]. On the other hand, low aerobic performance is associated with low capacity to release energy through oxidation processes for muscular work support, causing premature fatigue and difficulty in performing daily or physical activities [2]. Maximum oxygen uptake, the highest oxygen rate that the individual can consume during the performance of physical exercises, is the measure most widely used to evaluate aerobic performance, which can be determined through direct and indirect tests [3]. The methods commonly used in children and young people to evaluate aerobic performance are cycle ergometers and treadmills and walk or running tests [3]. Inadequate levels of aerobic performance in children and adolescents have been associated with risk factors of morbidity and premature mortality from all causes, especially

*Address correspondence to this author at the Universidade Federal de Santa Catarina, Centro de Desportos, Programa de Pós Graduação em Educação Física, Trindade, Florianópolis, SC, Brazil, 88010-970; Tel/Fax: (+55) 4837219462; E-mail: [email protected] 1573-3963/15 $58.00+.00

cardiovascular disease such as overweight [4], hypertension [4], insulin resistance [5], metabolic risk factors [5] and cognitive diseases [6]. Longitudinal study involving 25,714 Americans identified low level of aerobic performance as the main cause of mortality during 23 years of survey (19701993) regardless of the presence of other health problems [7]. Thus, the maintenance of adequate cardiorespiratory levels, by itself, may already be able to reduce health damages [1]. A secular-trend study has shown that aerobic performance levels in children and adolescents are decreasing [8]. In 27 countries evaluated in a survey between 1958 and 2003, there was a yearly decrease of 0.36% in aerobic performance [8]. This decrease in aerobic performance can be influenced by some individual characteristics. Demographic / biological factors such as black skin color [9], aging [10], female gender [2], economic factors such as low family income [11], aspects related to lifestyle such as physical inactivity [2] and excess body fat [2] have been associated in some studies with low aerobic performance levels. However, other studies have found no relationship between aerobic performance and these individual factors [2, 11-14]. The divergent results impose limitations for the planning of health promotion actions and control of the low aerobic performance level in adolescents. Thus, the identification of studies on the prevalence of low aerobic performance may contribute to the epidemiological knowledge of the subject and also in the analysis and discussion of socio-cultural aspects that influence the low aerobic performance. Further© 2015 Bentham Science Publishers

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more, when analyzing the evidence found of association between low aerobic performance and individual factors, it is possible to understand how these factors affect the aerobic performance of these individuals in order to promote effective interventions at community and school level. Thus, the aim of this systematic review was to identify studies on the prevalence of low aerobic performance levels and possible associations between low aerobic performance and demographic / biological factors, lifestyle and excess body fat in adolescents (11-19 years). The main hypothesis was that low levels of aerobic performance were associated with demographic / biological factors such as female gender, low levels of physical activity, excessive screen time and excess body adiposity in adolescents. METHOD A systematic review was conducted in March 2014 using Scientific Electronic Library Online (SciELO) and Medical Literature Analysis and Retrieval System Online (MEDLINE) electronic databases, accessed through PubMed. These two databases were also used in other studies [15, 16]. The justification for the use of two databases is that: a) In addition to being a completely free resource, developed and maintained by the National Library of Medicine (NLM) of the United States, PubMed is a database with over 5,400 journals indexed in 37 languages, containing over 16 million references to documents [17]; b) The SciELO database, also free, is an electronic library covering 1,187 journals from 17 countries (14 of them in Latin America). In the year 2013, more than 188,000 Brazilian papers were published in this database [18]. Descriptors were combined by operators And, Or and Not. The year of publication and the language of articles were disregarded in order to cover the largest possible number of studies, but no article not written in Portuguese or English was found (which were translated for assessment). The survey of information included different descriptors, considering the diversity of terminology found in literature for variable aerobic performance. The search was performed using the following descriptors: "aerobic capacity" or "aerobic fitness" or "cardiorespiratory capacity" or "cardiorespiratory fitness" or "aerobic power" or "aerobic endurance" or "cardiorespiratory endurance" and "adolescents". The same key words were also used in Portuguese language. The keywords of independent variables demographic / biological factors (skin color, age and sex), socioeconomic, lifestyle (screen time, eating habits, physical activity level, smoking, alcohol use) and excess body fat, not were included in the search to reduce the possibility of missing relevant publications. Thus, all titles that were indexed with keywords of aerobic performance were read to identify if they matched these independent variables and, consequently, the aerobic performance outcome. The following inclusion criteria were adopted: original research observational or experimental article; adolescents aged 11-19 years and mean age within this range; free full text using CAPES, which is a government agency in Brazil that provides free access to the full text of articles selected from various journals and databases in all areas of knowl-

Gonçalves et al.

edge. If any article was not made available by this system and the author’s contact was available in the database, the authors contacted the author via email to access the manuscript. Exclusion criteria were: review articles, monographs, dissertations, theses, abstracts, chapters or books and viewpoints / opinion of experts; articles exclusively involving adolescents with some kind of disease and / or mental and / or physical problem (anemia, cognitive problems, diabetes, depression, asthma, bronchitis, metabolic syndrome, physical disabilities). The authors of this study selected articles using a systematic method. First, titles of articles were read. Then, the abstracts were analyzed according to the inclusion criteria. After reviewing the abstracts, full articles were obtained and read and included if inclusion criteria were met. The references of all selected articles were examined to identify additional publications that should be reviewed and included. Fig. (1) shows the flowchart of the search, selection and reasons for the exclusion of references. The selection and evaluation of references were conducted by two researchers familiar with the methodology. In case of disagreement between two investigators, a third investigator gave the opinion on the article. General aspects of publication such as location and year of completion of the survey, study design, sample and subjects' age, aerobic performance tests that were used and the main findings were identified. Studies that associated aerobic performance and variables demographic / biological, socioeconomic, lifestyle and excess body fat were analyzed in relation to the percentage of concordance of evidence (Table 4). The concordance of results was estimated by the ratio between number of studies that have pointed out the association direction and the total number of studies reviewed. This procedure is used in reviews in the area of physical activity and allows identifying the correlation of findings [19]. RESULTS Overall, 465 articles were found in PubMed and SciELO databases, but 103 articles were duplicates, totaling 362 articles. The titles and abstracts of these 362 articles were read and after analysis, 30 articles that showed prevalence of low aerobic performance and / or were associated to factors investigated in this study (skin color, age, sex, economic status, screen time, eating habits, physical activity level, smoking, alcohol use and excess body fat) were selected. These 30 articles were read in full and three references that were not in the search were included in this review for being the most cited. Thus, 33 original articles were selected, seven related to the prevalence of low aerobic performance levels, four related to the association between low aerobic performance and skin color, 11 studies addressed the association between low aerobic performance and age, 17 articles associated the outcome with sex (male / female), five articles associated the outcome with economic level, one was related to eating habits, six articles associated low aerobic performance and physical activity levels, four articles associated screen time and 16 articles associated excess body fat. No article linking low aerobic performance levels with smoking and alcohol use was found in the search (Fig. 1).

Aerobic Performance Levels in Adolescents

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Fig. (1). Search, selection and exclusion of studies on the prevalence of low aerobic performance levels and associated factors.

Table 1 shows the characteristics of seven studies included with data on the prevalence of low aerobic performance. The highest prevalence of low aerobic performance was 61.7% [20]. When stratified by sex, the highest prevalence was 68% for males [10] and 39.4% for females [21]. Only one article in this search had longitudinal design [22]

and the other articles were cross-sectional [2, 11, 13, 20, 21, 23]. Of all studies, 42.9% were conducted in Brazil [11, 21, 23], 42.9% in European countries (UK, Portugal and Spain) [20, 22, 23] and 14.2% in the US [2]. The results in Table 2 demonstrated that the majority of studies (three of four articles) show differences in


Table 1.

Gonçalves et al.

Description of studies on prevalence of low levels of aerobic performance (%) in adolescentes according to the year and study site research, study design, sample and age, and aerobic performance test used.

Author(s)

Year and study site

Study design

Pate et al [2]

United States

Crosssectional Crosssectional

963 subjects Age 10 – 15 years

Multistage 20-meter shuttle run test

1999 - 2002 Vasques et al [11]

Florianopolis - Santa Catarina – Brazil

Sample and age group (years)

Aerobic performance test used

Prevalence of low aerobic performance (%)

3.287 subjects

Submaximal treadmill

35% of the adolescents

Age 12 – 19 years

exercise test 68% male 37% female

2004 - 2006 Stratton et al [22]

Liverpool – United Kingdom

Longitudinal

15.621 subjects Age nine – 11 years


23% sample

1998 – 2004 Ronque et al [21]

Londrina – Parana –

78 subjects

Crosssectional

Age 15 years

Crosssectional

Age 14 – 17 years

Crosssectional

Age 14 – 17 years

Crosssectional

Age 12 – 18 years


57,8% male 39,4% female

Brazil 2002 Petroski et al [23]

Januaria – Minas Gerais Brazil

627 subjects

1600 meter running/walking test

35,4% sample


61,7% sample


20,3% male

Year not mentioned Massuça e Proença [20]

Lisbon – Portugal

621 students

2009 Morales-Suárez-Varela et al [24]

Valencia – Spain 2009

583 subjects

aerobic performance according to skin color [9, 25, 26]. When comparing African-Americans and whites, AfricanAmericans had significantly lower aerobic performance levels [25]. In another study, African-Portuguese females showed significantly higher aerobic performance levels compared to white women [9]. In the United States, when comparing African-American, Hispanic and white girls, it was found that Hispanic girls had lower aerobic performance levels [26]. Only one study found no statistical difference between aerobic performance and skin color [2]. All studies had cross-sectional design, and three were developed in the United States [2, 25, 26] and one in Portugal [9]. Of the 11 included studies that examined the association between aerobic performance and age [2, 9-11, 13, 20, 27-31] (Table 2), one found no association between variables [13]. Three studies were included as positive and negative association (Table 4) because they have found divergent results when assessing the association between low aerobic performance and age in boys and girls [2, 29, 30]. Of the 11 studies, eight stratified data by sex [2, 9, 20, 27-31], and six of them found association between advancing age and better aerobic performance for males [2, 27-31] and five found association between advancing age and poor aerobic performance in females [2, 9, 20, 29, 30]. Only one study had longitudinal design [28], while the other studies were cross-sectional [2, 9-11, 13, 20, 27, 29-31]. Of included studies for variable age (n = 11), seven were developed in European countries [9, 13,

26% female

20, 28-31], three in South America [10, 11, 27] and one in the US [2]. Regarding sex, the results showed that in 89% of 17 studies, boys had better aerobic performance than girls [2, 9, 11, 14, 20, 22-24, 28, 29, 21-38] (Table 2). One study found that girls aged 14 years and boys aged 16 years had lower aerobic performance compared to peers, respectively [23]. Thus, this article was included as positive and negative association between low aerobic performance and sex (Table 4) [23]. One study found no association between low aerobic performance and sex [11]. Twelve studies had cross-sectional design [2, 9, 11, 20, 23, 24, 29, 32, 33, 35, 37, 38], three had longitudinal design [11, 22, 28] and two mixed design [34, 36]. Eight studies were conducted in European countries [9, 20, 22, 24, 28, 29, 32, 36], five in South America [11, 23, 33, 34, 38], two in the United States [2, 11] one in Africa [35] and one in Asia [37]. For socioeconomic status, results in Table 2 showed that 80% of five studies found association with aerobic performance, and adolescents belonging to lower socioeconomic classes had lower aerobic performance [10, 26, 39]. One study found no association between these variables [12]. All studies had cross-sectional design. Among included studies, three were conducted in Brazil [10-12], one in the US [26] and one in Europe [39]. Regarding the association between low aerobic performance and eating habits, only one article was found [32] (Table 3). The cross-sectional study was conducted in different


Table 2.


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Description of studies of demographic/biological variables (skin color, age, sex, and economic status) associated with aerobic performance (APE) in adolescents according to the year and study site research, study design, sample and age, aerobic performance test used and overall results.

Demographic/Biological variables

Author(s)

Year and study site

Study design



Overall results

Pate et al [2]

United States

Cross-sectional

3.287 subjects


Age 12 – 19 years

exercise test

No significant difference between APE and skin color

1.314 girls


Hispanics with lower levels of APE, followed by African American and White

Multistage treadmill test

African Americans with lower levels of APE as compared to whites

Age 12 – 18 years

Multistage 20meter shuttle run test

Caucasian girls with lower levels of APE as compared to African Portuguese

3.287 subjects


Age 12 – 19 years

exercise test

Male: Lower levels of APE in younger individuals.

1.052 subjects

Maximal cycle ergometer test

Male: Lower levels of APE in younger individuals


Male: Lower levels of APE in younger individuals

Skin color 1999 - 2002

Fahlman et al [26]

Midwestern – Texas

Cross-sectional

Mean age 16,2 ± 0,9 years

United States Year not mentioned Lee e Arslanian [25]

Pittsburgh – Pennsylvania – United States

Cross-sectional

113 subjects Age eight – 17 years

(among Non-Hispanic white, Non-Hispanic black and Mexican Americans)

Year not mentioned Santos et al [9]

Lisbon –

Cross-sectional

Portugal 1998 - 2004

266 subjects

Age Pate et al [2]

United States

Cross-sectional

1999 - 2002

Andersen et al [31]

Madeira - Portugal

Cross-sectional

Odensen Denmark Tartu Estonia

Female: Lower levels of APE in older individuals

Age nine e 15 years

Year not mentioned Rodrigues et al [27]

Vitoria –

Cross-sectional

Espírito Santo –


Brazil

exercise test

Year not mentioned Vasques et al [11]

Florianopolis –

Cross-sectional

Santa Catarina –


Brazil


Lower levels of APE in younger individuals

Cycle ergometer test


2004 – 2006 Slinger et al [28]

Limburg – Netherlands 2002 – 2005

Longitudinal

509 subjects Age 11 – 14 years 1.100 subjects Age 11 – 15 years

(for 509 subjects) Multistage 20meter shuttle run test (for 1.100 subjects)

(only Multistage 20meter shuttle run test)


Gonçalves et al.

(Table 2) contd… Demographic/Biological variables

Author(s)

Year and study site

Study design



Overall results

Finland

Cross-sectional

1.275 subjects

2000 meter running test for boys and 1500 meter running test for girls

No significant difference between APE and age



Age Huotari et al [13]

1976 e 2001

Age 13 – 18 years Kolle et al [29]

Norway –

Cross-sectional

European

Age nine e 15 years

2005 – 2006

Santos et al [9]

Lisbon –

Cross-sectional

Portugal Regions of mainland Portugal

Cross-sectional

Lisbon –

Cross-sectional

Portugal Cascavel –

Female: Lower levels of APE in older individuals. Multistage 20meter shuttle run test



Male: Lower levels of APE in younger individuals. Female: Lower levels of APE in older individuals

621 subjects




Lower levels of APE in older individuals.

Age 15 – 16 years


Lower levels of APE in female.

3.287 subjects



Age 12 – 19 years

exercise test

15.621 subjects




No significant difference between APE and sex.

Cycle ergometer test (for 509 subjects) Multistage 20meter shuttle run test (for 1.100 subjects)

Lower levels of APE in female (both tests).



Age 14 – 17 years

2009 Ribeiro et al [10]


Year not mentioned

Massuça e Proença [20]


1998 - 2004 MachadoRodrigues [30]

2.229 subjects

Cross-sectional

Parana –

1.317 subjects Age eight – 17 years

Brazil 2006 Sex Barwani et al [35]

Muscat – Oman

Pate et al [2]

United States

Cross-sectional

Year not mencioned Cross-sectional

1999 - 2002

Stratton et al [22]

Liverpool – United Kingdom

Longitudinal

1998 - 2004 Vasques et al [11]

Slinger et al [28]

Florianopolis –

Age nine – 11 years Cross-sectional

Santa Catarina – Brazil 2004 – 2006 Limburg –

Longitudinal

Netherlands

Norway – European 2005 – 2006

963 subjects Age 10 – 15 years 509 subjects Age 11 – 14 years 1.100 subjects Age 11 – 15 years

2002 – 2005

Kolle et al [29]

147 subjects

Cross-sectional

2.229 subjects Age nine - 15 years



(Table 2) contd… Demographic/Biological variables

Author(s)

Year and study site

Study design



Overall results

Silva et al [33]

Cariri region –

Cross-sectional


12 minutes running/walking test

Lower levels of APE in female

221 subjects in 1987

Submaximal progressive


537 subjects in 2001

protocol on a cycle ergometer

Sex Ceara – Brazil Year not mentioned Ekblom et al [36]

Sweden 1987, 2001 and 2007

Mixed longitudinal

265 subjects in 2007 Mean age 16.1 years Santos et al [9]

Lisbon –

Cross-sectional

Portugal

Age 12 – 18 years

1998 – 2004 Petroski et al [23]

Januaria –

266 subjects

Cross-sectional

Minas gerais –


Brazil




Female had lower levels of APE to 14 years. Male had lower levels of APE to 16 years

Year not mentioned Cuenca-Garcia et al [32]

Athens and Heraklion - Greece

Cross-sectional

Dortmund - Germany

1.492 subjects Age 12 – 17 years






Lower levels of APE in female with 12 to 15 years.



Progressive exercise test on a cycle ergometer

Lower levels of APE in female (in eutrophic)

Ghent - Belgium Lille – France Pecs - Hungary Roma - Italy Stockholm - Sweden Vienna - Australia Zaragoza - Spain 2006 - 2007 Mitchell et al [14] Musa e Williams [37]

United States

Longitudinal

Year not mentioned Benue – Nigeria

2.097 subjects Age 11 e 13 years

Cross-sectional

3.243 subjects Age nine – 11 years 2.226 subjects Age 12 – 15 years


Lisbon –

Cross-sectional

Portugal

Age 14 – 17 years

2009 Ferrari et al [34]

Ilha Bela – Sao Paulo – Brazil 1978/1980, 1988/1990, 1998/2000 and 2008/2010

621 subjects

Mixed longitudinal


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Gonçalves et al.

(Table 2) contd… Author(s)

Year and study site

Study design



Overall results

Arango et al [38]

Monteria – Cordoba – Colombia 2008

Cross-sectional

446 subjects



Morales-SuárezVarela et al [24]

Valencia – Spain

Cross-sectional



Fahlman et al [26]

Midwestern – Texas– United States

1.314 girls 1600 meter Mean age 16,2 running/walking test ± 0,9 years

Lower levels of APE in lower economic status level individuals

Demographic/Biological variables sex

Age 11 – 18 years

2009


Economic status Cross-sectional

Year not mentioned Vasques et al [11]

Pavón et al [39]

Florianopolis –

Cross-sectional

Santa Catarina – Brazil 2004 – 2006 Athens and Heraklion - Greece


Cross-sectional


Dortmund - Germany






No significant difference between APE and economic status


Lower levels of APE in lower economic status level individuals.

Ghent - Belgium Lille – France Pecs - Hungary Roma - Italy Stockholm - Sweden Vienna - Australia Zaragoza - Spain 2006 - 2007 Petroski et al [12]

Januaria –

Cross-sectional

Minas Gerais Brazil


Year not mentioned Ribeiro et al [10]

Cascavel – Parana – Brazil 2006

Cross-sectional


APE: Aerobic performance.

Table 3.

Description of variables lifestyle and excessive body fatness associated with aerobic performance in adolescents according to the year and study site research, study design, sample and age, aerobic performance test used and overall results.

Lifestyle and excessive body fatness

Author(s)

Year and study site

Study design



Overall results

Athens and Heraklion – Greece Dortmund - Germany Ghent - Belgium Lille – France Pecs - Hungary Roma – Italy Stockholm - Sweden Vienna - Australia Zaragoza – Spain 2006 - 2007

Crosssectional



Lower levels of APE associated with lower intakes of dairy products and/or bread/cereals and higher consumption of sweetened beverages.

Eating habits Cuenca-García et al. [32]



(Table 3) contd… Lifestyle and excessive body fatness

Author(s)

Year and study site

Study design



Overall results

Barwani et al [35]

Muscat – Oman Year not mencioned

Crosssectional



Lower levels of APE in individuals did not practice sport.

Bouziotas et al [40]

Katerini – Greece 1999

Crosssectional



Lower levels of APE in individuals with lower levels of physical activity.

Pate et al [2]

United States 1999 - 2002

Crosssectional


Submaximal treadmill exercise test

Lower levels of APE in individuals who practiced fewer moderate-high intensity physical activity.

Huotari et al [13]

Finland 1976 e 2001

Crosssectional



Lower levels of APE in individuals who do not practised leisure time physical activity.

Mitchell et al [14]

United States Year not mentioned

Crosssectional



No significant difference between APE and physical activity level.

MoralesSuárez-Varela et al [24]

Valencia – Spain 2009

Crosssectional



Lower levels of APE in individuals practicing physical activity frequency less than five times per week.

Pate et al [2]


Crosssectional



Lower levels of APE in individuals with more than three hours daily screen time.

Aggio et al [41]

East of England 2008 - 2010

Longitudinal

1.500 subjects Mean age 11,5 years


Lower levels of APE in individuals with more screen time.

Mitchell et al [14]

United States Year not mentioned

Longitudinal



Lower levels of APE in individuals with more screen time.

Sandercock et al [42]

West of England Year not mentioned

Crosssectional

6.819 subjects Age 10 - 16 years


Lower levels of APE in individuals with more screen time (only male).

Barwani et al [35]

Muscat – Oman Year not mentioned

Crosssectional



Lower levels of APE in individuals with more BMI (only female).

Bouziotas et al [40]

Katerini – Greece 1999

Crosssectional



Lower levels of APE in individuals with more body fatness.

Eisenmann et al [43]

Quebec – Canada Year not mentioned

Crosssectional

761 subjects Age nine – 18 years

Progressive exercise test on a cycle ergometer

Lower levels of APE in individuals with more BMI.

Pate et al [2]


Crosssectional



Lower levels of APE in individuals with overweight and obesity.

Eisenmann et al [44]

Australia Year not mentioned

Crosssectional



Lower levels of APE in individuals with high fat percentage.

Lee e Arslanian [25]

Pittsburgh – Pennsylvania – United States Year not mentioned

Crosssectional


Maximal treadmill exercise test

Lower levels of APE in individuals with higher rate of abdominal and visceral fat.

Ortega et al [45]

Spain Year not mentioned

Crosssectional

2.859 subjects Age 13 – 18,5 years


Lower levels of APE in individuals with more body fatness.

Rodrigues et al [27]

Vitoria – Espirito Santo – Brazil Year not mentioned

Crosssectional


Cardiopulmonary exercise testing


Stratton et al [22]

Liverpool – United Kingdom 1998 - 2004

Longitudinal




Physical activity level

Screen time

Excessive body fatness

9


Gonçalves et al.

(Table 3) contd… Lifestyle and excessive body fatness

Author(s)

Year and study site

Study design



Overall results

Huotari et al [13]

Finland 1976 e 2001

Crosssectional




Ronque et al [21]

Londrina – Parana – Brazil 2002

Crosssectional

78 subjects Age 15 years



Silva et al [33]

Cariri region – Ceara – Brazil Year not mentioned

Crosssectional


12 minutes running/walking test


Arango et al [38]

Monteria – Cordoba – Colombia 2008

Crosssectional




Ferrari et al [34]

Ilha Bela – Sao Paulo – Brazil 1978/1980, 1988/1990, 1998/2000 and 2008/2010

Mixed longitudinal


Submaximal progressive protocol on a cycle ergometer



Lisbon – Portugal 2009

Crosssectional



Lower levels of APE in individuals with higher fat mass percentage.

Ribeiro et al [10]

Cascavel – Parana – Brazil 2006

Crosssectional



Lower levels of APE in individuals with higher fat mass percentage.


APE: Aerobic performance; BMI: Body mass index.

regions of the European continent and found association between low aerobic performance and increased consumption of sweetened beverages, lower consumption of dairy products and bread / cereals [32]. Of the six studies that examined association between low aerobic performance and physical activity levels, 83% found that low physical activity levels are associated with lower aerobic performance levels (Table 3) [2, 13, 24, 35, 40]. One study of the six included in this section found no association between these variables [14]. All studies had cross-sectional design. Of the six studies included, two were conducted in the United States [2, 14], three in European countries [13, 24, 40] and one in Asia [35]. The four studies that examined association between low aerobic performance and screen time by means of time spent in TV / videos, computer / internet and video games found that adolescents who spent more time in front of the screen had low performance aerobic levels [2, 14, 41, 42]. Two studies had cross-sectional study [2, 42] and two had longitudinal design [14, 41], of these, two studies were conducted in the United States [2, 14] and two in England [41, 41]. The results of 16 studies on the association between low aerobic performance and excess body fat reached the same consensus that the higher the body fat the lower aerobic performance level (Table 3) [2, 10, 13, 20, 21, 23, 25, 27, 33-35, 38, 40, 43-45]. Fourteen studies had cross-sectional design [2, 10, 13, 20, 21, 25, 27, 33, 35, 38, 40, 43-45], one longitudinal design [22] and one mixed design [34]. Six studies were conducted in South America [10, 21, 27, 33,

34, 38], five in Europe [13, 20, 22, 30, 45], three in North America [2, 25, 43], one in Oceania [44] and one in Asia [35]. By analyzing the 33 articles included, it was found that 57.5% of them used the 20-meter Shuttle Run test [9-11, 14, 20-22, 24, 28, 30, 32, 35, 37-42, 45] as protocol for assessing aerobic performance, 18.2% used other field tests [12, 13, 23, 26, 33, 44] and the others performed treadmill [2, 25, 27] or cycle ergometer tests [28, 29, 31, 34, 36, 43]. In short, the results of studies showed a concordance among findings (Table 4) on the association between low aerobic performance and female gender, lower income, lower consumption of dairy products and / or bread / cereals, increased consumption of sweetened beverages and low physical activity levels. White skin color and age showed inconsistent results, sometimes with positive association, sometimes with negative, sometimes without association. Too much screen time and excess body fat showed 100% concordance of results, demonstrating that there is an association with low aerobic performance levels. DISCUSSION The main findings of this systematic review were that among the analyzed studies, female gender, low socioeconomic status, consumption of sweetened beverages, low physical activity level, excessive screen time and excess body fat were associated with low aerobic performance. Moreover, the higher prevalence of low aerobic performance


Table 4.


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Summary of evidence on the association between low levels of aerobic performance and variables demographic/biological, lifestyle and excessive body fatness. Association Positive

Negative

No association

% of studies

Agreement of the results

White skin color

9

25, 26

2

50%

?

Age

2, 11, 27, 28, 29, 30, 31

2, 9, 10, 20, 29, 30

13

50%

?

Female

2, 9, 14, 20, 22, 23, 24, 28, 29, 32, 33, 34, 35, 36, 37, 38

23

11

89%

+

Low economic status

10, 11, 26, 39

12

80%

+

100%

+

83%

+

Demographic/Biological variables

Lifestyle and excessive body fatness Eating habits*

32

Low physical activity level

2, 13, 24, 35, 40

Excessive screen-time**

2, 14, 41, 42

100%

+


2, 10, 13, 20, 21, 22, 25, 27, 33, 34, 35, 38, 40, 43, 44, 45

100%

+

14

? Inconclusive association; + positive association; - negative association; *Eating habits: lower intakes of dairy products and/or bread/cereals and higher consumption of sweetened beverages; **Screen time in front of television/videos, using computer/internet and/or playing video game.

levels in adolescents was 61.7% [20] and the lowest prevalence was 23% [22]. The prevalence of low aerobic performance ranged from 20.3% (Valencia, Spain) [24] to 68% (Florianopolis, Brazil) [11] for males and from 26% (Valencia, Spain) [24] to 39.4% (Londrina, Brazil) [21] for females. These differences may be due to cultural aspects that determine lifestyles [9]; variation in the use of protocols for assessing aerobic performance and cutoffs for classification [1] and age variations, since maturational aspects influence aerobic performance [11]. The literature is divergent regarding the association between low aerobic performance and skin color. The possible explanation for this inconclusive association may be attributed to the fact that the four studies found [2, 9, 25, 26] used different variables such as adjusting the association between skin color and aerobic performance. Variables such as age [9], body fat percentage [9], pubertal status [25], sex [25] and income [26] were used in some studies and not in others. This fact also demonstrates that there is still no consensus on possible mediators of the relationship between skin color and aerobic performance, which was evidenced in this review. The association between low aerobic performance and age should be carefully analyzed in this review. Table 4 presents the results without stratification by sex and therefore, there are studies that had both positive and negative association between low aerobic performance and age [2, 29, 30]. This occurred because in these studies, older girls showed lower aerobic performance levels and older boys showed higher aerobic performance levels. Results stratified by sex are conclusive to indicate that younger boys [2, 27-31] and older girls [2, 9, 20, 29, 30] showed low aerobic performance levels. The results found in this study confirm that women have lower aerobic performance than men. The differences between sexes are justified by biological maturation, since

VO2max in males increases throughout the period of puberty to adulthood. In girls, VO2max increased only at the beginning of puberty until the end of puberty, remaining unchanged from the end of puberty to adulthood [34]. Female behavioral aspects related to lower physical activity levels in school and out of it can also contribute to poor aerobic performance [34]. Regarding the association between aerobic performance and economic level, individuals of lower socioeconomic status had lower aerobic performance levels. This finding is discussed in literature by the fact that the economic level influences the practice of physical activity, since individuals with higher socioeconomic status are more likely to attend environments with adequate infrastructure for the practice of physical activities, access to supervised exercise programs and purchasing power to purchase sporting goods [39]. Groups of low socioeconomic status have reported perceived barriers to physical activity [26]. Another relevant aspect is that individuals with higher socioeconomic status tend to have higher education, which can affect the knowledge about the importance of having good health and performance and translate this knowledge into practice [39]. The only study included in this systematic review on the association between aerobic performance and eating habits found that lower consumption of dairy products and bread / cereals and increased consumption of sweetened beverages was associated with low aerobic performance levels [32]. Possibly, milk consumption is positively associated with aerobic performance due to the presence of components such as proteins [46], which help in muscle mass gains, inducing better aerobic performance [47]. The nutritional value of sweetened drinks compared to dairy products is much lower. Sweetened beverages are considered as nutrients with empty calories, i.e., they have low nutritional value, and due to their high sugar percentage, they are associated with several cardiovascular risk factors [47]. The consumption of bread and cereals is essential to the practice of physical activity and


good aerobic performance, since its function is to provide energy for the development and maintenance of physical efforts [48]. Most studies (83.3% of six studies) found positive association between aerobic performance and physical activity level. Literature confirms that insufficient practice or even the performance of low-intensity activities is not sufficient to reach the minimum threshold necessary for the occurrence of significant cardiorespiratory adaptations [1]. As a result, low aerobic performance levels can be observed [1]. All studies included in this review that associated time spent watching television / videos, using computer / internet and / or playing video games and aerobic performance showed that adolescents who spend more time with electronics had low aerobic performance levels. Literature shows that this occurs because during the time spent in front of electronics adolescents fail to perform more active activities, resulting in low physical activity and aerobic performance levels [49]. Finally, excess body fat was also associated with low aerobic performance levels in all studies [2, 10, 13, 20, 21, 22, 25, 27, 33-35, 38, 40, 43-45]. This may occur because individuals with higher amount of body fat tend to have walking difficulties, decreased frequency of steps and less stability during walking and / or running [50]. These aspects influence the economy of movements, resulting in greater energy expenditure and early fatigue in lower intensity activities [50]. It is noteworthy that the variety of protocols used in studies to evaluate aerobic performance levels makes the comparison of results difficult. In this review, studies that used submaximal [2, 34] and maximum [10, 16, 18, 21, 23, 24, 31, 33, 36, 38, 41-43] exercise protocols were found. The use of submaximal protocols for estimating VO2max has lower accuracy than maximum protocols [2]; however, they are more practical to apply in larger populations [14]. Some study limitations should be considered. It was not possible to apply an instrument to determine the quality score of studies. Studies showed different designs and lack of methodological information (e.g., cutoffs for some variables, exercise protocols, formulas for estimating VO2max, control of confounding variables, among others), which made the use of a tool that could include all studies impossible. The application of a single instrument could produce inaccurate scores, which would lead to wrong judgments and damages for the quality of conclusions. The inclusion of free access articles is also considered a study limitation, since many papers on the subject may not have been selected in the systematic search. However, the inclusion of free access articles in this review can encourage, even slightly, more journals to adhere to the free access of their manuscripts. Furthermore, the inclusion of free access manuscripts allows readers to read and analyze all the articles included in this systematic review. The independent selection of articles by two researchers (with disagreements being resolved by a third investigator) and the number of variables that were analyzed to identify possible associations with low aerobic performance among adolescents, which were chosen in order to bring greater

Gonçalves et al.

panorama of possible factors correlated to low aerobic performance levels, stand out as strengths of this study. Female gender, low socioeconomic status, low physical activity level, consumption of sweetened beverages, excessive screen time and excess body fat were correlated to low aerobic performance levels in adolescents aged 11-19 years. The association with aerobic performance was inconclusive for skin color and age. CONFLICT OF INTEREST The authors confirm that this article content has no conflict of interest ACKNOWLEDGEMENTS The author ECAG thanks CAPES/Brazil for the scholarship. The author HEGN thanks UNIEDU/Brazil for the scholarship. REFERENCES [1] [2]

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Revised: ???????? ??, 201?

Accepted: ??????? ??, 201?