ArticlePDF Available

Abstract and Figures

Purpose: This study was aimed to analyze the mediation role of cardiorespiratory fitness (CRF) on the association between fatness and cardiometabolic risk scores (CMRs) in European adolescents. Methods: A cross-sectional study was conducted in adolescents (n = 525; 46% boys; 14.1 § 1.1 years old, mean § SD) from 10 European cities involved in the Healthy Lifestyle in Europe by Nutrition in Adolescence study. CRF was measured by means of the shuttle run test, while fatness measures included body mass index (BMI), waist to height ratio, and fat mass index estimated from skinfold thicknesses. A clustered CMRs was computed by summing the standardized values of homeostasis model assessment, systolic blood pressure, triglycerides, total cholesterol/high-density lipoprotein cholesterol ratio, and leptin. Results: Linear regression models indicated that CRF acted as an important and partial mediator in the association between fatness and CMRs in 12�17-year-old adolescents (for BMI: coefficients of the indirect role b = 0.058 (95% confidence interval (95%CI): 0.023�0.101), Sobel test z = 3.11 (10.0% mediation); for waist to height ratio: b = 4.279 (95%CI: 2.242�7.059), z =3.86 (11.5% mediation); and for fat mass index: b = 0.060 (95%CI: 0.020�0.106), z = 2.85 (9.4% mediation); all p < 0.01). Conclusion: In adolescents, the association between fatness and CMRs could be partially decreased with improvements to fitness levels; therefore, CRF contribution both in the clinical field and public health could be important to consider and promote in adolescents independently of their fatness levels.
Content may be subject to copyright.
Original article
Mediation role of cardiorespiratory fitness on the association between
fatness and cardiometabolic risk in European adolescents:
The HELENA study
Carlos Cristi-Montero
*, Javier Courel-Ib
, Francisco B. Ortega
, Jose Castro-Pi~
Alba Santaliestra-Pasias
, Angela Polito
emy Vanhelst
, Ascensi
on Marcos
Luis M. Moreno
, Jonatan R. Ruiz
, on behalf of the HELENA study group
IRyS Group, Physical Education School, Pontificia Universidad Cat
olica de Valparai
so, Valparai
so 2530388, Chile
Department of Physical Activity and Sport, Faculty of Sport Sciences, University of Murcia, Murcia 30071, Spain
PROmoting FITness and Health through Physical Activity Research Group (PROFITH), Department of Physical Education and Sports,
Faculty of Sport Sciences, University of Granada, Granada 18001, Spain
Department of Physical Education, Faculty of Education Sciences, University of C
adiz, Puerto Real 11003, Spain
Department of Health and Human Performance, School of Health Sciences, University of Zaragoza, Zaragoza 50001, Spain
Growth, Exercise, Nutrition and Development (GENUD) Research Group, Zaragoza 50001, Spain
National Institute for Food and Nutrition Research, Rome 80070, Italy
Lille Inflammation Research International Center, University of Lille, Lille 59000, France
Immunonutrition Research Group, Department Metabolism and Nutrition, Institute of Food Science and Technology and Nutrition (ICTAN),
Spanish National Research Council (CSIC), Madrid E-28040 Spain
Received 20 September 2018; revised 25 February 2019; accepted 9 June 2019
Available online 16 August 2019
2095-2546/Ó2021 Published by Elsevier B.V. on behalf of Shanghai University of Sport. This is an open access article under the CC BY-NC-ND license.
Purpose: This study was aimed to analyze the mediation role of cardiorespiratory fitness (CRF) on the association between fatness and cardiome-
tabolic risk scores (CMRs) in European adolescents.
Methods: A cross-sectional study was conducted in adolescents (n= 525; 46% boys; 14.1 §1.1 years old, mean §SD) from 10 European cities
involved in the Healthy Lifestyle in Europe by Nutrition in Adolescence study. CRF was measured by means of the shuttle run test, while fatness
measures included body mass index (BMI), waist to height ratio, and fat mass index estimated from skinfold thicknesses. A clustered CMRs was
computed by summing the standardized values of homeostasis model assessment, systolic blood pressure, triglycerides, total cholesterol/high-
density lipoprotein cholesterol ratio, and leptin.
Results: Linear regression models indicated that CRF acted as an important and partial mediator in the association between fatness and CMRs in
1217-year-old adolescents (for BMI: coefficients of the indirect role b= 0.058 (95% confidence interval (95%CI): 0.0230.101), Sobel test
z= 3.11 (10.0% mediation); for waist to height ratio: b= 4.279 (95%CI: 2.2427.059), z=3.86 (11.5% mediation); and for fat mass index:
b= 0.060 (95%CI: 0.0200.106), z= 2.85 (9.4% mediation); all p<0.01).
Conclusion: In adolescents, the association between fatness and CMRs could be partially decreased with improvements to fitness levels; therefore, CRF
contribution both in the clinical field and public health could be important to consider and promote in adolescents independently of their fatness levels.
Keywords: Cardiovascular disease; Children; Fat mass; Fitness; Health; Physical activity
1. Introduction
Obesity in adolescents has increased dramatically in recent
decades and has reached worldwide pandemic proportions.
Obese youths are likely to become obese adults and are at
Peer review under responsibility of Shanghai University of Sport.
* Corresponding author.
E-mail address: (C. Cristi-Montero).
Cite this article: Cristi-Montero C, Courel-Ib
nez J, Ortega FB, et al. Mediation role of cardiorespiratory fitness on the association between fatness and cardiome-
tabolic risk in European adolescents: The HELENA study. J Sport Health Sci 2021;10:3607.
Available online at
Journal of Sport and Health Science 10 (2021) 360367
higher risk of developing cardiovascular diseases (CVD), dys-
lipidemia, and type 2 diabetes,
which together constitute the
main cause of death in adults.
Both unhealthy dietary behav-
iors and physical inactivity
seem to be the key determinants
of obesity in youth; thus, early interventions for preventing the
development of obesity-related CVD are needed not only for
present health but also for future health.
To date, there has been no absolute clarity regarding the
reverse or bidirectional relationship (causeeffectresponse)
between obesity and physical inactivity because the direction of
causality cannot be inferred from cross-sectional associations.
There is evidence from longitudinal studies that shows reciprocal
associations and synergistic interactions among fatness with
motor skill competence, physical activity, and cardiorespiratory
fitness (CRF).
In contrast, there are other studies that show
that fatness leads to inactivity in children.
These circumstance
expose the ambiguity of the scientific literature in this matter and
the need to investigate the interaction between fatness and fitness.
Of note is that physically inactive adolescents have lower
CRF levels;
and, in turn, this physiological marker is cru-
cial for attenuating the association between fatness and
increased cardiometabolic risk from childhood to adoles-
Hence, nowadays there is a special focus on improv-
ing CRF,
especially in obese adolescents.
An interesting approach to studying the role and importance of
a variable over the association between others is mediation analy-
sis, which can determine whether a predictor variable in an out-
come is mediated through an intermediate variable (mediator).
This innovative method has been applied in studies of children to
examine the mediator role of obesity in the relationship between
CRF and cardiometabolic risk
and inflammation.
The authors
of these studies reported that, when including body mass index
(BMI) as a mediator, the association between CRF and cardiome-
tabolic risk disappears completely in girls and is considerably miti-
These results do not fully support the “fat-but-fit”
paradigm, which suggests that a person with excess adiposity but
with a high CRF (fat-fit phenotype) has a better cardiometabolic
profile than a person with excess adiposity but with a low
Accordingly, the role of fitness and fatness as mediators
of cardiometabolic health still needs to be clarified, especially in
children and adolescents.
Based on the assumption that fatness leads to inactivity, the
purpose of this study was to analyze the mediation role of CRF
on the association between fatness markers and cardiometabolic
risk scores (CMRs) clustering in European adolescents and to
analyze the magnitude of CRF mediation in this relationship.
We hypothesized that CRF would only partially mediate the
relationship between fatness and CMRs. This investigation con-
tributes to the field of public health by providing evidence about
the bidirectional relationship between obesity and CRF.
2. Methods
The Healthy Lifestyle in Europe by Nutrition in Adoles-
cence (HELENA) cross-sectional study was designed to obtain
reliable and comparable data on nutrition and health-related
parameters from a sample of adolescents aged
12.517.5 years from 10 European cities in 9 countries. Data
collection took place between 2006 and 2008. A sample of
3528 adolescents met the HELENA general inclusion criteria
(age of 13.0016.99 years, schooling in one of the 10 Euro-
pean cities, informed consent signed, had at least weight and
height measured, and completed at least 75% of the other
In the present study, 525 adolescents (54% girls) with
valid data on the main variables and covariates were included
in the analysis: cardiometabolic risk factors, including total
cholesterol to high-density lipoprotein cholesterol ratio
(TC/HDL-C), triglycerides (TG), homeostasis model assess-
ment (HOMA), and systolic blood pressure (SBP); as well as
leptin, CRF, age, sex, pubertal stage, and center (city involved
in the study from each country). This subsample was represen-
tative to the total sample (assuming an error of 5%, a confi-
dence interval (CI) of 95%, and 50% of heterogeneity).
Moreover, there were no differences between the present sub-
sample and the whole sample (boys and girls separately) in
terms of age, body mass, height, and BMI (all p>0.05).
The study was performed following the ethical guidelines
of the 1964 Declaration of Helsinki (revision of Edinburgh
2000), Good Clinical Practice, and legislation regarding clini-
cal research in humans in each of the participating countries.
The protocol was approved by the Human Research Review
Committees of the involved centers. Furthermore, all parents
and guardians signed an informed consent form, and the ado-
lescents agreed to participate in the study.
2.1. Physical examination
Adolescents participating in the study were barefoot and
dressed in light clothing during anthropometric measurements.
Body weight was measured to the nearest 0.1 kg with an elec-
tronic scale (Seca 861; Seca GmbH & Co., Hamburg, Ger-
many), and body height was measured with a telescopic
stadiometer (Seca 225; Seca GmbH & Co.) to the nearest
0.1 cm. BMI was calculated as body weight divided by the
square of height (kg/m
Waist circumference (WC) was
measured with a non-elastic tape (Seca 200; Seca GmbH &
Co.) to the nearest 0.1 cm. Waist to height ratio (WHtR) was
then calculated by dividing WC (cm) by height (cm). Bicipital,
tricipital, subscapular, and suprailiac skinfold thicknesses on
the left side of the body were measured with a Holtain Calliper
(Holtain Ltd., Crymych, Wales, UK) to the nearest 0.2 mm.
All the anthropometric measurements were taken 3 times and
the mean was scored.
Percentage of body fat was calculated
using the equation of Slaughter et al.,
which has proven to be
the most suitable equation for use with adolescents.
Fat mass
(kg) was estimated by multiplying body fat percent by weight
(kg) and dividing by 100, and fat-free mass (kg) was calculated
as the difference between body weight and fat mass. Fat mass
index (FMI) was determined by dividing fat mass (kg) by
height squared (m
). Identification of pubertal maturation
(Stages IV) was assessed by direct observation by a medical
doctor, according to Tanner and Whitehouse.
SBP was mea-
sured (OMRONÒM6, HEM 70001; Omron, Kyoto, Japan) fol-
lowing the recommendations for adolescent populations,
Mediation role of cardiorespiratory fitness 361
with participants seated in a separate quiet room for 10 min
with their backs supported and feet on the ground. Two SPB
readings were taken at 10-min intervals, and the lowest mea-
sure was recorded.
2.2. Blood samples
Blood samples were collected as previously described.
TG, TC, and HDL-C were measured using enzymatic methods
(Dade Behring, Schwalbach, Germany). All blood parameters
were measured after an overnight fast. HOMA index calculation
was used as a measure of insulin resistance
using the formula
HOMA-index = (insulin (mUI/mL) £glucose (mg/dL))/405.
The ratio of TC/HDL-C was also calculated. Leptin con-
centrations were measured by the RayBio (RayBiotech
Inc., GA, USA) Human Leptin enzyme-linked immunosor-
bent assay. Leptin assay sensitivity was set at less than 6
pg/mL, with intraclass and interclass coefficients of varia-
2.3. CRF
CRF was measured by the progressive 20-m shuttle run test.
The test has high validity and reliability in adolescents
(testretest reliability coefficients were 0.89; standard error of
estimation was 5.9 mL/kg/min).
In the shuttle run test, par-
ticipating adolescents ran between 2 lines 20 m apart, while
keeping the pace with audio signals emitted from a pre-recorded
CD with an initial speed of 8.5 km/h and increasing by 0.5 km/h
every minute (1 min equals 1 stage). The test ended either when
the adolescent failed to reach the end line concurrent with the
audio signals on 2 consecutive occasions or when he or she
stopped owing to fatigue. The last stage completed (precision of
0.5 stages) was used to calculate the maximal oxygen consump-
tion from the equation developed by L
eger et al.
2.4. CMRs
A summative cardiometabolic risk index that includes sev-
eral factors has proven to be a better marker of cardiovascular
health in children than an index that only includes a single risk
CMRs were created from the sum of SBP, TG,
TC/HDL-C ratio, HOMA, and leptin z-scores. The standard-
ized value (z-scores) of each variable was calculated as
follows: (valuemean)/SD, separately for boys and girls, and
for each 1-year age group. Lower values are indicative of a
better profile.
This risk profile has been used previously in a
cross-sectional study of 1732 randomly selected 9-year-old
and 15-year-old school children from 3 European countries
and in 2015.
Andersen et al.
confirmed that the composite
risk score improved substantially in a sample of 15,794 youths
aged 618 years that included the HOMA index rather than
fasting glucose, leptin, the sum-of-4-skinfolds (instead of BMI
or WC), and CRF. Both the sum-of-4-skinfolds and CRF were
removed from this CMRs because these were part of the medi-
ation analysis and could have generated a methodological
2.5. Statistical analysis
The normality of the distribution of the variables was
tested using both statistical (KolmogorovSmirnov test) and
graphical methods (normal probability plot). Adolescents’
characteristics are presented as the mean §SD and the fre-
quency (%) for continuous and categorical variables, respec-
tively. The Student ttest and the Pearson’s x
test were used
to test sex differences in relation to adolescents’ CRF, fatness
(BMI, WHtR, and FMI), and cardiometabolic biomarkers
(TC/HDL-C, TG, HOMA, SBP, and leptin) and pubertal
stage. Partial correlation coefficients (r), adjusted for age,
sex, pubertal stage, and center, were used as a preliminary
analysis to examine the associations between CRF, cardiome-
tabolic, and fatness biomarkers.
Multicollinearity was tested before completing the media-
tion analysis through tolerance value and variance inflation
We analyzed the mediation role of CRF on the
association of 3 fatness markers (BMI, WHtR, and FMI) with
CMRs through bootstrapped (10,000 samples) linear regres-
sion analyses
using the PROCESS SPSS script,
for age, sex, pubertal stage, fat-free mass, and center. Each
model included 3 equations.
Equation 1 regressed the mediator (CRF) on the indepen-
dent variable (BMI, WHtR, and FMI). Equation 2 regressed
the dependent variable (CMRs) on the independent variable
(BMI, WHtR, and FMI). Equation 3 regressed the dependent
variable (CMRs) on both the independent (BMI, WHtR, and
FMI) and the mediator variable (CRF), and Equation 30took
into account the indirect (mediating) role. We calculated
the percentage of the total contribution that is accounted for by
mediation using the standardized coefficients of the Equation
1£Equation 2 / Equation 3. A significant “indirect role”
(mediation) was established when (a) the independent variable
was significantly related to the mediator, (b) the independent
variable was significantly related to the dependent variable, (c)
the mediator was significantly related to the dependent vari-
able, and (d) the association between the independent and
dependent variable (“direct role”) was attenuated when the
mediator was included in the regression model.
The Sobel
test was used to test the hypothesis that the indirect role was
equal to 0.
Point estimates and 95% confidence intervals
(95%CIs) were estimated for the indirect role. Complete medi-
ation was established when the independent variable (fatness)
was not associated with the dependent variable (CMRs) after
mediator (CRF) has been controlled, making path Equation 30
zero. Partial mediation is when the path from fatness to CMRs
is reduced in absolute size but is still different from 0 when the
mediator is introduced. The percentage of mediation was cal-
culated as 1(Equation 30/ Equation 3) where Equation 3 is
the role for the independent variable in predicting the main
outcome and Equation 30is the role of the independent variable
in predicting the dependent variable with the mediator vari-
able. Analyses were completed using the IBM SPSS (Version
21.0; IBM Corp., Armonk, NY, USA). The level of signifi-
cance was set at p<0.05.
362 C. Cristi-Montero et al.
3. Results
Table 1 shows the characteristics of the sample. The partial
correlations coefficients between the fatness variables, CRF,
and cardiometabolic biomarkers are presented in Table 2.
There was no difference in the CMRs between sex (p= 0.992)
when both boys and girls were grouped. CRF was negatively
associated with all the study measures of fatness as well as
with cardiometabolic biomarkers (p<0.05), except for SBP.
BMI, WHtR, and FMI were associated positively with all car-
diometabolic biomarkers (p<0.05). We observed no multi-
collinearity. The tolerance value ranged between 0.829 and
0.888 for collinearity tolerance and the variance inflation fac-
tor ranged between 1127 and 1206 for collinearity.
The results from mediation analysis are shown in Fig. 1.
Overall, fatness (BMI, WHtR, and FMI) was positively associ-
ated with CMRs. Mediation analysis including CRF revealed
that the association between fatness and CMRs was mediated
via CRF. The role of this mediation adjusted for potential con-
founders accounted for around 10%. More precisely, CRF medi-
ates 10.0% of CMRs for BMI (z= 3.11; indirect role = 0.058
(95%CI: 0.0230.101); p= 0.001), 11.5% for WHtR (z=3.86;
indirect role = 4.279 (95%CI: 2.2427.059); p<0.001), and
9.4% for FMI (z= 2.85; indirect role = 0.060 (95%CI:
0.0200.106); p= 0.004) parameters.
4. Discussion
The main findings of the current study indicate that CRF
acts as a partial mediator in the association between 3 different
fatness variables and clustered CMRs in European adolescents.
Therefore, although it is true that CRF is an important health
biomarker, it does not seem to completely counteract the nega-
tive role of fatness on cardiometabolic health. To our knowl-
edge, this is one of the few studies that have used CRF as a
and the first to establish the mediation role of
Table 1
Characteristics of adolescents.
Overall (n= 525) Boys (n= 241) Girls (n= 284)
Age (year) 14.1 §1.1 14.2 §1.2 14.1 §1.1
Body mass (kg) 56.9 §12.3 59.0 §13.3 55.2 §11.2*
Height (cm) 164.7 §9.7 168.9 §10.2 161.1 §7.5*
BMI (kg/m
) 20.8 §3.4 20.5 §3.3 21.1 §3.5*
Pubertal stage I/II/III/IV/V (%) 0.8/6.8/21.3/37.4/29.0 1.7/9.1/20.9/34.1/30.3 0.0/5.1/21.6/39.9/28.0
Fat mass (kg) 13.5 §8.2 11.6 §9.0 15.1 §7.2*
Fat-free mass (kg) 43.4 §8.1 47.4 §8.9 40.1 §5.5*
Waist circumference (cm) 71.1 §8.2 72.3 §8.1 70.0 §8.2*
WHtR 0.43 §0.04 0.43 §0.04 0.43 §0.04
CRF (mL/kg/min) 41.1 §7.8 46.0 §7.2 37.0 §5.6*
FMI (kg/m
) 4.9 §2.9 4.0 §3.0 5.7 §2.6*
TC (mg/dL) 161.0 §26.9 153.1 §24.0 167.7 §27.4*
HDL-C (mg/dL) 55.6 §10.5 53.4 §9.7 57.5 §10.9*
Triglycerides (mg/dL) 69.1 §35.4 62.4 §29.4 74.8 §38.9*
HOMA 2.4 §2.0 2.3 §2.4 2.4 §1.6
SBP (mmHg) 117.0 §13.1 120.9 §13.8 113.8 §11.6*
Leptin (ng/dL) 19.3 §22.0 9.3 §14.6 27.8 §23.5*
Notes: Values are mean §SD or frequency (%). Independent two-tailed ttests or x
tests were applied to compare unadjusted means by sex.
*p<0.05, compared with boys.
Abbreviations: BMI = body mass index; CRF = cardiorespiratory fitness; FMI = fat mass index; HDL-C = high-density lipoprotein cholesterol; HOMA = homeosta-
sis model assessment; SBP = systolic blood pressure; TC = total cholesterol; WHtR = waist to height ratio.
Table 2
Partial correlations coefficients (r) among fatness, CRF, and cardiometabolic biomarkers.
CRF — — — — — — —
BMI 0.318*————— —— —
WHtR 0.323*0.892*———— —— —
FMI 0.409*0.909*0.852*——— —— —
SBP 0.030 0.356*0.339*0.288*—— —— —
TC/HDL-C 0.161*0.233*0.253*0.219*0.026 —
TG 0.148*0.196*0.218*0.216*0.011 0.449*—— —
HOMA 0.240*0.336*0.313*0.344*0.170*0.141*0.381*——
Leptin 0.322*0.635*0.632*0.683*0.185*0.149*0.227*0.320*
Note: Model was adjusted for age, sex, pubertal stage, and center.
*p<0.05, significant association.
Abbreviations: BMI = body mass index; CRF = cardiorespiratory fitness; FMI = fat mass index; HOMA = homeostasis model assessm ent; SBP = systolic blood pressure;
TC/HDL-C = total cholesterol to high-density lipoprotein cholesterol ratio; TG = triglycerides; WHtR = waist to height ratio.
Mediation role of cardiorespiratory fitness 363
CRF on the relationship between fatness and cardiometabolic
risk in European adolescents.
The evidence shows a close relationship among fatness,
low CRF, and cardiometabolic health in youths.
CRF and obesity as predictors of CVD should be monitored
to identify children and adolescents with potential CVD
Despite the importance of both markers on cardio-
metabolic health, mediation analysis studies have frequently
used fatness as a mediator,
assuming a possible unique
association way (physical inactivity as causal of fatness).
However, there is also literature showing otherwise.
looking at the 2 sides of the coin seems to be adequate for
achieving a broader and objective understanding of this prob-
lem to improve the effectiveness of intervention programs in
this population.
The results of the present mediation analysis show that CRF
is capable of partially attenuating the association between fat-
ness and a cluster of cardiometabolic risk factors in adoles-
cents. In this sense, the magnitude of the mediation of CRF
could support—up to a point—the fat-but-fit hypothesis,
Fig. 1. Mediation analysis. Contribution of fatness on CMRs through CRF, adjusting for potential confounders (age, sex, pubertal stage, center, and fat-free mass).
BMI = body mass index; CMRs = cardiometabolic risk scores; CRF = cardiorespiratory fitness; FMI = fat mass index; WHtR = waist to height ratio.
364 C. Cristi-Montero et al.
because a high level of CRF would not fully protect the inde-
pendent action of fatness (BMI, WHtR, and FMI) on cardio-
metabolic risk in adolescents. However, the independent and
beneficial role of high CRF may indeed offset more of the fat-
ness risk than indicated by the mediator analysis—just by
mechanisms not related to fatness. It should be noted that this
mediation role is around 10% for the 3 fatness variables stud-
ied in this approach, which gives it an important role both in
public health strategies and for clinical purposes.
This outcome is in line with previous prospective research
reporting that in schoolchildren (aged 711 years) the associa-
tion of CRF with change in CVD risk factor levels after adjust-
ment for adiposity (total body fat, BMI, and WC) was less
strong and concluding that the association of CRF with CVD
risk factors was largely explained by adiposity.
study of schoolchildren (aged 1014 years) showed that chil-
dren with low fitness levels had increased odds of presenting
both individual and clustered cardiometabolic risk factors, but
these associations no longer remained after adjusting for
abdominal adiposity.
The authors suggested that abdominal
adiposity may be a more important determinant of adverse car-
diometabolic health in this age group,
and especially in
obese children.
Notwithstanding the foregoing, childhood
CRF seems to decrease the long-term (20-year follow-up of
1792 adults) cardiometabolic risks associated with childhood
Therefore, more studies exploring the symbiotic
interaction between fatness and CRF on cardiometabolic
health are warranted to establish insight into the bidirectional
causality between these variables.
The physiological interpretation of these findings is com-
plex because fatness and CRF are separately and indepen-
dently associated with cardiometabolic risk factors,
possibly exerting their effects through different causal path-
For example, obesity may result in the develop-
ment of a chronic, low-grade inflammatory state caused by
an increased expression of pro-inflammatory adipokines and
diminished expression of anti-inflammatory adipokines.
Moreover, obesity has been associated with elevated oxida-
tive stress, which can lead to endothelial dysfunction.
has also been related to a decrease in oxygen respiration in
skeletal muscle associated with an impairment of mitochon-
drial function.
Each condition mentioned (chronic low-grade inflammatory
state, diminished antioxidant capacity, and decrease in oxygen
respiration in skeletal muscle) can be improved or even
reversed, to some extent, by adequate levels of physical activ-
ity and exercise
and by enhancing CRF.
meta-analysis showed that high-intensity interval training
seems to be more effective for improving cardiometabolic risk
and CRF than other forms of exercise in overweight and obese
High-intensity activities, particularly among adoles-
cents, seems to be more effective in reducing a clustered meta-
bolic syndrome for both fit and unfit individuals.
our results contribute to the existing evidence by suggesting
that if younger individuals maintain adequate CRF levels, this
can play a protective role that partially counteracts the harmful
role of obesity.
This work has some important strengths, such as the size of
the European sample used (multicentric study) and the use of
high-quality harmonization methods. It also seems to be the
first study that has used CRF as a mediator to analyze CRF’s
role in relation to a cluster of cardiometabolic risk factors in
adolescents. However, this study also has certain limitations.
The present mediation analysis should be interpreted as
exploratory given the cross-sectional nature of our study; thus,
it does not allow conclusions about the causality relationships
to be drawn. Future longitudinal and experimental studies are
needed to confirm our results.
Although it is true that CRF was measured with a validated
and reliable test, this variable depends heavily on body weight.
This situation could lead to underestimations of CRF values in
people with overweight and obesity
and underestimate the
benefit of the fat-but-fit hypothesis.
Moreover, the use of
clustered CMRs is specific to the study sample, and each factor
is equally weighted in predicting future disease. Finally, the
sample used in this study was made up of relatively healthy
youths, which could hamper the sensitivity in detecting associ-
5. Conclusion
CRF in adolescents seems to act as a significant and partial
mediator of the relationship between fatness and CMRs, which
supports, to a certain extent, the fat-but-fit paradigm. These
results suggest that the independent role of CRF is associated
with other mechanisms that are not directly linked to fatness.
However, these findings also indicate that maintaining ade-
quate CRF levels among adolescents can counteract the devel-
opment of harmful obesity-related CVDs and thus is an
important public health strategy.
We thank the adolescents who participated in the study
and their parents and teachers for their collaboration. We also
acknowledge the HELENA study members involved in field-
work for their efforts. The HELENA project was supported
by the European Community 6th Framework Programme for
Research and Technological Development (contract FOOD-
CT-2005-007034). The data for this study were gathered
under the aegis of the HELENA project, and further analysis
was additionally supported by the Spanish Ministry of Econ-
omy and Competitiveness (Grants RYC-2010-05957 and
RYC-2011-09011), the Spanish Ministry of Health: Maternal,
Child Health and Development Network (Grants RD08/0072
and RD16/0022), the Fondo Europeo de Desarrollo Regional
(MICINN-FEDER), and the University of Granada, Plan Pro-
pio de Investigaci
on 2016, Excellence Actions: Units of
Excellence; Unit of Excellence on Exercise and Health
(UCEES). The content of this article reflects the authors’
views alone, and the European Community is not liable for
any use that may be made of the information contained
Mediation role of cardiorespiratory fitness 365
Authors’ contributions
CCM and JRR had full access to all of the data in the
study and took responsibility for the integrity of the data and
the accuracy of the data analysis; CCM and JCI conceived
and designed the study and drafted the manuscript; FBO,
JCP, ASP, AP, JV, AM, LMM, and JRR carried out critical
revisions of the manuscript for important intellectual content.
All authors have read and approved the final version of the
manuscript, and agree with the order of presentation of the
Competing interests
The authors declare that they have no competing interests.
1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national preva-
lence of overweight and obesity in children and adults during 19802013:
A systematic analysis for the Global Burden of Disease Study 2013. The
Lancet 2014;384:766–81.
2. Arellano-Ruiz P, Garc
ıa-Hermoso A, Mart
ıno V, Salcedo-
Aguilar F, Garrido-Miguel M, Solera-Martinez M. Trends in cardiometa-
bolic parameters among Spanish children from 2006 to 2010: The Cuenca
study. Am J Hum Biol 2017;29:e22970. doi:10.1002/ajhb.22970.
3. Ajala O, Mold F, Boughton C, Cooke D, Whyte M. Childhood predictors
of cardiovascular disease in adulthood. A systematic review and meta-
analysis. Obes Rev 2017;18:1061–70.
4. World Health Organization. Global status report on noncommunicable
diseases. Geneva: World Health Organization; 2014.
5. Vilallonga R, Moreno Villares JM, Yeste Fern
andez D, et al. Initial
approach to childhood obesity in Spain. A multisociety expert panel
assessment. Obes Surg 2017;27:997–1006.
6. Metcalf BS, Hosking J, Jeffery AN, Voss LD, Henley W, Wilkin TJ.
Fatness leads to inactivity, but inactivity does not lead to fatness: A
longitudinal study in children (EarlyBird 45). Arch Dis Child
7. Hjorth MF, Chaput JP, Ritz C, et al. Fatness predicts decreased physical
activity and increased sedentary time, but not vice versa: Support from a
longitudinal study in 8- to 11-year-old children. Int J Obes 2014;38:959–
8. Lima RA, Pfeiffer KA, Bugge A, Møller NC, Andersen LB, Stodden DF.
Motor competence and cardiorespiratory fitness have greater influence on
body fatness than physical activity across time. Scand J Med Sci Sport
9. Lima RA, Bugge A, Ersbøll AK, Stodden DF, Andersen LB. The lon-
gitudinal relationship between motor competence and measures of fat-
ness and fitness from childhood into adolescence. J Pediatr (Rio J)
10. Stodden DF, Goodway JD, Langendorfer SJ, et al. A developmental per-
spective on the role of motor skill competence in physical activity: An
emergent relationship. Quest 2008;60:290–306.
11. Santos R, Mota J, Okely AD, et al. The independent associations of seden-
tary behaviour and physical activity on cardiorespiratory fitness. Br J
Sports Med 2014;48:1508–12.
12. Lagestad P, Mehus I. The importance of adolescents’ participation in
organized sport according to VO
A longitudinal study. Res Q Exerc
Sport 2018;89:143–52.
13. Brouwer SI, Stolk RP, Liem ET, Lemmink KA, Corpeleijn E. The role of
fitness in the association between fatness and cardiometabolic risk from
childhood to adolescence. Pediatr Diabetes 2013;14:57–65.
14. Ross R, Blair SN, Arena R, et al. Importance of assessing cardiorespira-
tory fitness in clinical practice: A case for fitness as a clinical vital sign: A
scientific statement from the American Heart Association. Circulation
15. Cummings DM, DuBose KD, Imai S, Collier DN. Fitness versus fatness
and insulin resistance in U.S. Adolescents. J Obes 2010;2010: 195729.
16. Hayes A. Introduction to mediation, moderation, and conditional process
analysis: A regression-based approach. New York, NY: Guilford Press;
17. D
andez A, S
opez M, Mora-Rodr
ıguez R, Notario-
Pacheco B, Torrijos-Ni~
no C, Mart
ıno V. Obesity as a mediator
of the influence of cardiorespiratory fitness on cardiometabolic risk: A
mediation analysis. Diabetes Care 2014;37:855–62.
18. Garcia-Hermoso A, Agostinis-Sobrinho C, Mota J, Santos RM, Correa-
Bautista JE, Ram
elez R. Adiposity as a full mediator of the influ-
ence of cardiorespiratory fitness and inflammation in schoolchildren: The
FUPRECOL study. Nutr Metab Cardiovasc Dis 2017;27:525–33.
19. Ortega FB, Ruiz JR, Labayen I, Lavie CJ, Blair SN. The fat but fit paradox:
what we know and don’t know about it. Br J Sports Med 2017;52:151–3.
20. Moreno LA, De Henauw S, Gonz
alez-Gross M, et al. Design and imple-
mentation of the Healthy Lifestyle in Europe by Nutrition in Adolescence
cross-sectional study. Int J Obes 2008;32(Suppl. 5):S4–11.
21. Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-
offs for thinness, overweight and obesity. Pediatr Obes 2012;7:284–94.
22. Nagy E, Vicente-Rodriguez G, Manios Y, et al. Harmonization process
and reliability assessment of anthropometric measurements in a multicen-
ter study in adolescents. Int J Obes 2008;32(Suppl. 5):S58–65.
23. Slaughter MH, Lohman TG, Boileau RA, et al. Skinfold equations for
estimation of body fatness in children and youth. Hum Biol 1988;60:709–
24. Rodr
ıguez G, Moreno LA, Blay MG, et al. Body fat measurement in ado-
lescents: comparison of skinfold thickness equations with dual-energy
X-ray absorptiometry. Eur J Clin Nutr 2005;59:1158–66.
25. Tanner JM, Whitehouse RH. Clinical longitudinal standards for height,
weight, height velocity, weight velocity, and stages of puberty. Arch Dis
Child 1976;51:170–9.
26. National High Blood Pressure Education Program Working Group on
High Blood Pressure in Children and Adolescents. The fourth report on
the diagnosis, evaluation, and treatment of high blood pressure in children
and adolescents. Pediatrics 2004;114:555–76.
27. Gonz
alez-Gross M, Breidenassel C, G
ınez S, et al. Sampling
and processing of fresh blood samples within a European multicenter
nutritional study: Evaluation of biomarker stability during transport and
storage. Int J Obes 2008;32(Suppl. 5):S66–75.
28. Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner
RC. Homeostasis model assessment: Insulin resistance and beta-cell func-
tion from fasting plasma glucose and insulin concentrations in man. Dia-
betologia 1985;28:412–9.
29. Labayen I, Ruiz J, Ortega F, et al. Association between the FTO
rs9939609 polymorphism and leptin in European adolescents: A possible
link with energy balance control. The HELENA study. Int J Obes
30. L
eger LA, Mercier D, Gadoury C, Lambert J. The multistage 20 metre
shuttle run test for aerobic fitness. J Sports Sci 1988;6:93–101.
31. Olds T, Tomkinson G, L
eger L, Cazorla G. Worldwide variation in the
performance of children and adolescents: An analysis of 109 studies of
the 20-m shuttle run test in 37 countries. J Sports Sci 2006;24:1025–38.
32. Andersen LB, Harro M, Sardinha LB, et al. Physical activity and clustered
cardiovascular risk in children: A cross-sectional study (The European
Youth Heart Study). The Lancet 2006;368:299–304.
33. Andersen LB, Lauersen JB, Brønd JC, et al. A new approach to define and
diagnose cardiometabolic disorder in children. J Diabetes Res 2015;2015:
539835. doi:10.1155/2015/539835.
34. Menard S. Applied logistic regression analysis: Sage university series on
quantitative applications in the social sciences. California, CA: Sage Pub-
lications Inc; 2002.
35. Myers RH. Classical and modern regression with applications. Boston,
MA: Duxbury Press;1990.
36. Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assess-
ing and comparing indirect effects in multiple mediator models. Behav
Res Methods 2008;40:879–91.
366 C. Cristi-Montero et al.
37. Baron RM, Kenny DA. The moderator-mediator variable distinction in
social psychological research: Conceptual, strategic, and statistical con-
siderations. J Pers Soc Psychol 1986;51:1173–82.
38. Sobel ME. Asymptotic confidence intervals for indirect effects in struc-
tural equation models. Sociol Methodol 1982;13:290–312.
39. Segura-Jim
enez V, Parrilla-Moreno F, Fern
andez-Santos JR, et al. Physi-
cal fitness as a mediator between objectively measured physical activity
and clustered metabolic syndrome in children and adolescents: The
UP&DOWN study. Nutr Metab Cardiovasc Dis 2016;26:1011–9.
40. Muntaner-Mas A, Pere P, Vidal-Conti J, Esteban-Cornejo I. A media-
tion analysis on the relationship of physical fitness components, obe-
sity, and academic performance in children. J Pediatr 2018;198:90–7.
41. Steele RM, Brage S, Corder K, Wareham NJ, Ekelund U. Physical activ-
ity, cardiorespiratory fitness, and the metabolic syndrome in youth. J Ado-
lesc 2008;105:342–51.
42. Pozuelo-Carrascosa DP, S
opez M, Cavero-Redondo I, Torres-
Costoso A, Bermejo-Cantarero A, Mart
ıno V. Obesity as a
mediator between cardiorespiratory fitness and blood pressure in pre-
schoolers. J Pediatr 2017;182:114–9.
43. Countryman AJ, Saab PG, Llabre MM, Penedo FJ, McCalla JR, Schnei-
derman N. Cardiometabolic risk in adolescents: Associations with physi-
cal activity, fitness, and sleep. Ann Behav Med 2013;45:121–31.
44. Castro-Pi~
nero J, Perez-Bey A, Segura-Jim
enez V, et al. Cardiorespiratory
fitness cutoff points for early detection of present and future cardiovascu-
lar risk in children. Mayo Clin Proc 2017;92:1753–62.
45. Seo YG, Choi MK, Kang JH, et al. Cardiovascular disease risk factor clus-
tering in children and adolescents: A prospective cohort study. Arch Dis
Child 2018;103:968–73.
46. D
andez A, S
opez M, Gul
alez R, et al. BMI as a
mediator of the relationship between muscular fitness and cardiometabolic
risk in children: A mediation analysis. PLoS One 2015;10: e0116506.
47. Ortega FB, Lavie CJ, Blair SN. Obesity and cardiovascular disease. Circ
Res 2016;118:1752–70.
48. Klakk H, Grøntved A, Møller NC, Heidemann M, Andersen LB, Wedder-
kopp N. Prospective association of adiposity and cardiorespiratory fitness
with cardiovascular risk factors in healthy children. Scand J Med Sci Sport
49. Bailey DP, Savory LA, Denton SJ, Kerr CJ. The association between car-
diorespiratory fitness and cardiometabolic risk in children is mediated by
abdominal adiposity: The HAPPY study. J Phys Act Heal 2015;12:
50. Nystr
om CD, Henriksson P, Mart
ıno V, et al. Does cardiorespi-
ratory fitness attenuate the adverse effects of severe/morbid obesity on
cardiometabolic risk and insulin resistance in children? A pooled analysis.
Diabetes Care 2017;40:1580–7.
51. Schmidt MD, Magnussen CG, Rees E, Dwyer T, Venn AJ. Childhood fit-
ness reduces the long-term cardiometabolic risks associated with child-
hood obesity. Int J Obes 2016;40:1134–40.
52. LaMonte MJ, Blair SN. Physical activity, cardiorespiratory fitness, and
adiposity: contributions to disease risk. Curr Opin Clin Nutr Metab Care
53. Pedersen BK, Febbraio MA. Muscles, exercise and obesity: Skeletal mus-
cle as a secretory organ. Nat Rev Endocrinol 2012;8:457–65.
54. Nakamura K, Fuster JJ, Walsh K. Adipokines: A link between obesity and
cardiovascular disease. J Cardiol 2014;63:250–9.
55. Huang CJ, McAllister MJ, Slusher AL, Webb HE, Mock JT, Acevedo EO.
Obesity-related oxidative stress: The impact of physical activity and diet
manipulation. Sport Med Open 2015;1:32. doi:10.1186/s40798-015-0031-y.
56. Safdar A, Khrapko K, Flynn JM, et al. Exercise-induced mitochon-
drial p53 repairs mtDNA mutations in mutator mice. Skelet Muscle
2016;6:7. doi:10.1186/s13395-016-0075-9.
57. Ruiz JR, Huybrechts I, Cuenca-Garcia M, et al. Cardiorespiratory fitness
and ideal cardiovascular health in European adolescents. Heart
58. Garc
ıa-Hermoso A, Cerrillo-Urbina AJ, Herrera-Valenzuela T, Cristi-
Montero C, Saavedra JM, Mart
ıno V. Is high-intensity interval
training more effective on improving cardiometabolic risk and aerobic
capacity than other forms of exercise in overweight and obese youth? A
meta-analysis. Obes Rev 2016;17:531–40.
59. Krachler B, Savonen K, Komulainen P, Hassinen M, Lakka TA, Raura-
maa R. Cardiopulmonary fitness is a function of lean mass, not total body
weight: The DRs EXTRA study. Eur J Prev Cardiol 2015;22:1171–9.
60. Silva DR, Werneck AO, Collings PJ, et al. Cardiorespiratory fitness effect
may be under-estimated in “fat but fit” hypothesis studies. Ann Hum Biol
Mediation role of cardiorespiratory fitness 367
... In addition, the obesity variable that show higher association was WC, followed of BMI and FM, respectively. These same results were found in the study of Cristi-Montero et al. (2019) and being in conrcondance with these authors (Cristi-Montero et al., 2019), this is an important found for public health strategic and clinical purpose. ...
... In addition, the obesity variable that show higher association was WC, followed of BMI and FM, respectively. These same results were found in the study of Cristi-Montero et al. (2019) and being in conrcondance with these authors (Cristi-Montero et al., 2019), this is an important found for public health strategic and clinical purpose. ...
... Cristi-Montero et al., 2019;Díez-Fernández et al., 2014; Pozuelo-Carrascosa et al., 2017) but CRF act as a protector of cardiometabolic risk factor and might act as an attenuate elevation MBP in children with overweight or obesity(Cristi-Montero et al., 2019;Nyström et al., 2017;Ogunleye et al., 2012). In acordance with cardiometabolic risk, Cristi-Montero et al. ( ...
The aims of this study were a) to assess whether obesity acts as a mediator between i) cardiorespiratory fitness (CRF) and mean blood pressure; and ii) between between physical activity (PA) and mean blodd pressure in children and adolescents. A cross-sectional study was conducted with a 632 children and adolescents. It was measured mean blood pressure, body mass index, fat mass and waist circumference. CRF and PA was assessing with Course Navette test and ActiGraph. The analysis of the mediation was performed using Process macro for SPSS. The results indicate that obesity acts as a partial mediation in the association between CRF and mean blood pressure in 10-12 years old children (z=from -5.81 to -5.40; all p˂0.000). These results indicate that obesity acts as a complete mediator in the association between PA and mean blood pressure in 10-12 years old children (z=from -4.49 to -1.94; all p˂0.000). Our result reinforces the relevance of prevent weight increse and improve cardiorespiratory fitness level since erly age in children and adolescents to prevent high mean blood pressure. Increasing the level of physical activity can influence on obesity and cardiorespiratory fitness.
... In addition, the improvements in CRF presented different results in obesity and normal weight groups, in this sense, it is observed that high CRF influence excessive body weight and cardiovascular disease mortality, being able of promoting improvements in the cardiometabolic risk factors related to obesity, only in obese individuals [25,26]. Other study demonstrated that CRF seems to be a mediator in the relationship between BF%, BMI, and waist-to-height ratio with cardiometabolic risk factors, indicating that high CRF seems to compensate for the negative effect of adiposity in the cardiometabolic risk factors [27]. In contrast, some studies indicated that high CRF levels seem not to be able to reduce high blood pressure or cardiometabolic risk factors in children [28][29][30], indicating that is important to maintain normal body weight and high CRF to cardiovascular health [31]. ...
... However, some limitations also should be pointed out, the use of both 6-and 9-min running and walking tests to evaluate CRF, to minimize this limitation the estimation of VO 2peak was calculated. Also, these tests are indirect measure of CRF, although this evaluation is commonly used in many studies [26,27]. The reliability and validity could have been stronger if gold-standard protocols were utilized, such as VO 2peak maximum protocol for CRF and DXA for adiposity assessments. ...
Full-text available
Background A better understanding of how cardiorespiratory fitness (CRF) and adiposity interact to associate with arterial blood pressure over time remains inconclusive. Thus, the aim of the present study was to examine whether changes in CRF moderates the association between body fat percentage (BF%) and arterial blood pressure in children and adolescents. Methods This is an observational longitudinal study with 407 children and adolescents aged 8–17 years followed-up for three years from a city in Southern Brazil. Participants were evaluated in 2011 and 2014. CRF was measured by validated field-based tests following the Projeto Esporte Brazil protocols and peak oxygen uptake (VO2peak) was estimated. BF% was determined by the measures of tricipital and subscapular skinfolds using equations according to sex. Systolic and diastolic blood pressure (SBP, DBP) were measured with a sphygmomanometer according to standard procedures. Moderation analyses included multiple linear regression models adjusted for sex, age, pubertal status, height, socioeconomic level, skin color, and the arterial blood pressure variable itself at baseline. Results It was observed a significant inverse association between VO2peak at baseline with SBP (β = − 0.646 CI95% = − 0.976 − 0.316) and DBP (β = − 0.649 CI95% = − 0.923 − 0.375) at follow-up and a positive association between BF% at baseline with SBP (β = 0.274; CI95% = 0.094 0.455) and DBP (β = 0.301; CI95% = 0.150 0.453) at follow-up. In addition, results indicated a significant interaction term between changes in VO2peak and BF% at baseline with both SBP (p = 0.034) and DBP at follow-up (p = 0.011), indicating that an increase of at least 0.35 mL/kg/min and 1.78 mL/kg/min in VO2peak attenuated the positive relationship between BF% with SBP and DBP. Conclusion CRF moderates the relationship between BF% and SBP and DBP in children and adolescents.
... 16,17 In the light of the observations mentioned above, it is necessary to consider whether and how the level of cardiorespiratory fitness may determine the effects of HIIT in the form of adipose tissue reduction. The literature provides mainly observations of simple relationships between the above substitutions [10][11][12][13][14] . HIIT training requires intensive effort. ...
... To a certain extent, this finding supports the fat-but-fit paradigm, which was observed in other studies. 14 These results suggest that the independent role of cardiorespiratory fitness is associated with different mechanisms that are not directly liked to HIIT. However, these findings also indicate that maintaining adequate cardiorespiratory fitness among adolescents can counteract the potential development of metabolic diseases and thus is important for general health care. ...
Background: High-intensive interval training (HIIT) is an effective way to reduce body fat. Numerous studies confirmed the effectiveness of the HIIT for cardiorespiratory fitness development. Fewer studies examined the relationship between these factors in one dependencies model in overweight and obese adolescents. Therefore, the main aim of this study was to examine whether cardiorespiratory fitness mediated the relationship between HIIT and body fat % and whether sex moderated this relation. Methods: 36 students (15 boys and 21 girls) aged 16.02±0.39 years were examined. Participants were assigned to the HIIT intervention or control group. The intervention lasted 14 minutes during one physical education lesson per week for ten weeks. Harvard step-test results which reflected cardiorespiratory fitness and body fat % received via bioimpedance, were analyzed. Results: Mediation analysis was conducted in the whole group because sex was not a moderator in any associations (p>0.05). HIIT intervention was associated with reducing body fat% (B=-3.63, p=0.029) and improvement of cardiorespiratory fitness (B=4.487, p<.001). Simultaneously, body fat% was significantly mediated by changes in cardiorespiratory fitness (B=-2.21, p<0.049). Significant effect of HIIT on body fat% decreased (Bdirect<Btotal) and no longer was significant after including cardiorespiratory fitness (B=-1.42, p=0.431). Conclusions: HIIT training is an effective method of reducing body fat% and improving cardiorespiratory fitness. A higher cardiorespiratory fitness level may be conducive to increasing the effectiveness of HIIT training, which translates into a more effective reduction of body fat. Due to the lack of sex moderation in the observed relationships, this effect occurs in both sexes.
... Also, the applied analyzes made it possible to establish the level of CRF that children and adolescents must achieve to protect against cardiometabolic risk when NC is considered. The relationship between CRF and different anthropometric indicators has been widely shown in the literature, which includes an inverse association with BMI, waist circumference, and waist to height ratio [42][43][44][45][46]. However, much less is known about the relation between CRF and NC. ...
... Confirming the idea that appropriate levels CRF, indeed, can mitigate the consequences of body adiposity on cardiometabolic health, although our data showed that only very high CRF levels exert a protection. Still, it is suggested that regardless of body weight, it is important to achieve appropriate CRF levels [44,52,53]. This aspect is of great relevance, mainly when considering that the development of different cardiometabolic risk factors has its origin in childhood and can be taken to adulthood [54]. ...
Full-text available
Background The increased incidence of cardiometabolic risk factors has become a public health issue, especially in childhood and adolescence. Thus, early identification is essential to avoid or reduce future complications in adulthood. In this sense, the present study aimed to verify the influence of cardiorespiratory fitness (CRF) as a moderator in the association between neck circumference (NC) and cardiometabolic risk in children and adolescents. Methods Cross-sectional study that included 2418 randomly selected children and adolescents (52.5% girls), aged 6 to 17 years old. Anthropometric measurements, such as NC and body mass index (BMI), and CRF was measured by the six-minute running/walking test, as well as cardiometabolic risk (systolic blood pressure, glucose, HDL-C, and triglycerides), were assessed. Results For all age groups, NC showed a negative relationship with CRF. A significant interaction term was found for CRF x NC with cardiometabolic risk for children (6 to 9 years old), early adolescents (10 to 12 years old), and middle adolescents (13 to 17 years old). It was found that children who accomplished more than 1092.49 m in CRF test were protected against cardiometabolic risk when considering NC. In adolescents, protection against cardiometabolic risk was found when the CRF test was completed above 1424.14 m and 1471.87 m (early and middle stage, respectively). Conclusions CRF is inversely associated with NC and acts as a moderator in the relationship between NC and cardiometabolic risk in children and adolescents. Therefore, this detrimental health impact linked to fatness might be attenuated by improving CRF levels.
... In addition, the relationships between fitness status and performance (i.e., are fit players more successful than unfit players?) and injury risks (i.e., are fit players more likely to suffer an injury than unfit players?) are to be explored yet. The use of mediation analysis could be considered for describing, discovering, and testing possible causal relationships; that is, whether the relationship between two variables (e.g., cardiorespiratory fitness status and body composition) is explained by a third intermediate variable (e.g., regular padel practice experience) [76]. ...
Full-text available
Benefits of regular exercise for health are beyond any doubt. However, adherence to regular physical activity is an ongoing challenge. Among the options for exercise engagement, racket sports, and particularly padel, stand as emerging practices for children and adults to have fun, improve physical fitness, and potentially develop motor and cognitive skills. In the last decade, the literature on padel is increasing exponentially. However, there is a need for further experimental research. To design safe and effective sport-base physical activity promotion interventions, it is essential to have a deep understanding of the physical requirements, technical complexity, injury risks, and strength and conditioning programs. To assist researchers to conduct effective padel-based interventions for health, this review summarizes the state-of-the-art evidence about padel, identifies key topics to be addressed in the future, and discusses the potential role of padel as a physical fitness and health promotion strategy. A narrative review is presented, summarizing the results of padel articles from three different databases: Web of Science, Scopus, and Google Scholar. Studies written in Spanish and English were the inclusion criteria. The studies had to be published from 2000 onwards and be original, as well as peer-reviewed.
... As physical fitness has an impact on cardiovascular health and lipid profile [63], we performed a detailed assessment using CRF, UBMS, and LBES tests, which are recognized as the most reliable tools to evaluate physical fitness [64]. ...
Full-text available
Cardiovascular diseases are the leading cause of mortality worldwide. These diseases originate in childhood, and a better understanding of their early determinants and risk factors would allow better prevention. The BELINDA (BEtter LIfe by Nutrition During Adulthood) study is a 10–14-year follow-up of the HEalthy Lifestyle in Europe by Nutrition in Adolescence study (the HELENA study, a European cross-sectional study in adolescents). The study aims to evaluate cardiovascular risk using the PDAY (Pathobiological Determinants of Atherosclerosis in Youth) risk score during young adulthood (21–32 years), and to examine the impact of risk factors identified during adolescence (12.5–17.5 years). Our secondary objective is to compare the characteristics of the BELINDA study population with the HELENA population not participating in the follow-up study. The HELENA study recruited 3528 adolescents during 2006–2007 and reassessed 232 of them 10–14 years later as young adults. We assessed clinical status, anthropometry, nutrition, physical activity (including sedentary behavior), physical fitness, and mental health parameters, and collected biological samples (blood, stool, and hair). Dietary intake, and physical activity and fitness data were also collected. A multivariable linear regression model will be used for the analysis of the primary outcome. A Chi-square and T-test were conducted for the comparison of the descriptive data (gender, age, weight, height, body mass index (BMI), and maternal school level) between participating and non-participating BELINDA adolescents. When comparing the 1327 eligible subjects with the 232 included in the BELINDA study, no significant differences regarding gender (p = 0.72), age (p = 0.60), height (p = 0.11), and weight (p = 0.083) at adolescence were found. However, the participating population had a lower BMI (20.4 ± 3.1 kg/m2 versus 21.2 ± 3.6 kg/m2; p < 0.001) and a higher maternal educational level (46.8% high school or university level versus 38.6%; p = 0.027) than the HELENA population who did not participate in the BELINDA study. The complete phenotyping obtained at adolescence through the HELENA study is a unique opportunity to identify adolescent risk factors for cardiovascular diseases. This paper will serve as a methodological basis for future analysis of this study.
... Low CRF associates with poor cardiometabolic health (10,12), whereas altered arterial structure (PWV) is directly associated with poor cardiometabolic health in adolescence (30). A mediation study reported that the association of increased fat mass with poor cardiometabolic health in children could be decreased by increasing CRF because CRF had a 10% indirect or mediating role (31). Besides, the association of increased fat mass with altered arterial structure (PWV) is influenced by cardiometabolic health (29). ...
Full-text available
Purpose: To determine whether estimated cardiorespiratory fitness (CRF), fat mass (FM), lean mass (LM) and adiponectin bi-directionally associate with arterial function and structure and if CRF mediates the relationship between cardiometabolic health and arterial outcomes in 9-11-year-old children using the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort, UK. Methods: Brachial artery flow-mediated dilation (FMD), distensibility coefficient (DC) and carotid-radial pulse wave velocity (PWV) was measured by ultrasonography; CRF was measured during submaximal ergometer test; total and trunk FM and LM by dual-energy Xray absorptiometry; plasma adiponectin by enzyme assay; and cardiometabolic health was computed using International Diabetes Federation criteria. We tested bi-directionality by including CRF, FM, LM, and adiponectin as exposures and FMD, DC, and PWV as outcomes, alternatively. Results: Among 5566 participants (2816 [51%] girls, median age 9.75 years), CRF/body mass-0.21 was directly related to DC (β [95% CI]) = 0.004 [<0.0001 to 0.008]; P = 0.046) while CRF/LM-0.54 was inversely associated with PWV (-0.034 [-0.063 to -0.003]; 0.032) after adjusting for covariates. These associations remained in bi-directional analyses. Total and trunk FM and LM were bi-directionally and positively associated with FMD and DC. Total and trunk FM but not LM had bi-directional and inverse associations with PWV. Adiponectin was not related to FMD, DC or PWV. CRF partially mediated the associations of cardiometabolic health with FMD (1.5% mediation); DC (12.1% mediation); and PWV (3.5% mediation). Conclusions: Associations of poor cardiometabolic health with adverse arterial structure and function in childhood may be mitigated by increasing CRF. CRF and body composition were directly associated with arterial function. In the reverse analysis, better arterial function was associated with higher CRF and total FM.
... This is relevant in todays' world, considering that insufficient physical activity has raised the level of unhealthy body composition, e.g., overweight and obesity are at epidemic proportions with an alarming increase of ten-fold over the last forty years [13]. Interestingly, while natural sex differences in body composition and physical fitness could exist during childhood [14,15], increments in cardiovascular fitness through exercise positively contribute to reducing excess weight and cardiometabolic risk factors (body mass index, waist to hip ratio, and fat mass index) in adolescents, regardless of sex [16]. Accordingly, table tennis can be an effective strategy to encourage children and adolescents to undertake regular physical activity for optimal health outcomes and to limit sedentary behavior, particularly recreational screen time [17]. ...
Full-text available
The aim of this study was to identify the differences in body composition and physical fitness between children who played table tennis regularly during a two-year period compared to physically active children who were not engaged in a regular activity. Three hundred seventy-four children aged 10 to 11 years were divided into two groups: table tennis players (n = 109 boys and 73 girls) and physically active group (n = 88 boys and 104 girls). Anthropometric analysis included body mass index, skinfolds, perimeters and bone diameters. Somatotype and body composition were determined according to age-specific equations. Physical fitness assessment included hand grip dynamometry (strength), sit-and-reach test (range of movement) and maximal multistage 20 m shuttle run test (cardiovascular fitness). The result show that children who regularly played table tennis had greater bone development and superior physical fitness compared to those who were physically active but not engaged in a regular physical activity. This is the largest study to date presenting data about the potential of table tennis to benefit health in children. These results constitute an important first step in clarifying the effectiveness of table tennis as a health-promotion strategy
... Thus, assessing physical fitness has emerged as a proxy of the health status of children and adolescents and consequently as relevant from a public health point of view (Ortega et al., 2008b;Cadenas-Sanchez et al., 2016). In this regard, several research projects have been conducted to establish both normative values of school populations Ortega et al., 2011a;De Miguel-Etayo et al., 2014;Tomkinson et al., 2017;Cadenas-Sanchez et al., 2019;Kolimechkov et al., 2019) and cut-off points in the outputs of fitness tests that identify health risk profiles in children and youth (Ruiz et al., 2016;Castro-Piñero et al., 2019;Cristi-Montero et al., 2019;Lang et al., 2019). These approaches are usually based on cross-sectional designs that provide information associated to a determined time-point. ...
Full-text available
Assessing physical fitness has emerged as a proxy of the health status of children and adolescents and therefore as relevant from a public health point of view. DAFIS is a project included in Plan Galicia Saudable (Healthy Galicia Plan) of the regional government of Galicia (Spain). DAFIS consists of an on-line software devoted to record the results of a standard physical fitness protocol carried out as a part of the physical education curriculum. The aims of this study were: to obtain normative values of physical fitness of the Galician school population evaluated in the DAFIS project, and to identify a reduced number of components and tests able to capture a significant amount of the variability in the physical fitness of children and adolescents. From an initial sample of 27784 records, 15287 cases (7543 males, 7744 females) were considered after filtering. Generalized Additive Models for Location, Scale and Shape were used for obtaining percentile curves and tables for each sex. Furthermore, a principal components analysis was performed, selecting the number of components by applying the Kaiser´s rule and selecting a subset of variables considering the correlation between each variable and the components. Percentile curves and normative values are reported for each test and sex. Physical fitness was better in boys than in girls throughout age groups, except for flexibility that was consistently higher in girls. Two main components were detected throughout age groups: the first one representing body composition and partially cardiorespiratory fitness and the second one muscular fitness. For boys and girls, waist to height ratio had the highest correlations with the first component in four out of six age groups. The highest correlation with the second component, was most frequently observed for the handgrip test both in boys and girls (four out of six age groups). This study provides evidence about the utility of school community actions like DAFIS aimed to track the health-related fitness of children and adolescents. The results suggest that fat mass distribution (i.e., waist to height ratio and waist circumference) and muscular performance (mainly handgrip) concentrate a high proportion physical fitness variance.
Full-text available
Background: Physical fitness and fatness converge simultaneously modulating cognitive skills, which in turn, are associated with children and adolescents' socioeconomic background. However, both fitness components and fat mass localization are crucial for understanding its implication at the cognitive level. Objective: This study aimed to determine the mediation role of a global physical fitness score and its components on the association between different fatness indicators related to fat distribution and adolescents' cognitive performance, and simultaneously explore the influence of school vulnerability. Methods: In this study, 1,196 Chilean adolescents participated (aged 10-14; 50.7% boys). Cardiorespiratory fitness (CRF), muscular fitness (MF), and speed-agility fitness (SAF) were evaluated, and a global fitness score (GFS) was computed adjusted for age and sex (CRF + MF + SAF z-scores). Body mass index z-score (BMIz), sum-of-4-skinfolds (4SKF), and waist-to-height ratio (WHtR) were used as non-specific, peripheral, and central adiposity indicators, respectively. A global cognitive score was Frontiers in Behavioral Neuroscience | 1 September 2021 | Volume 15 | Article 746197 Hernández-Jaña et al. Fitness, Fatness, and Cognition computed based on eight tasks, and the school vulnerability index (SVI) was registered as high, mid or low. A total of 24 mediation analyses were performed according to two models, adjusted for sex and peak high velocity (Model 1), and adding the school vulnerability index (SVI) in Model 2. The significance level was set at p < 0.05. Results: The fitness mediation role was different concerning the fatness indicators related to fat distribution analyzed. Even after controlling for SVI, CRF (22%), and SAF (29%), but not MF, mediated the association between BMIz and cognitive performance. Likewise, CRF, SAF and GFS, but not MF, mediated the association between WHtR and cognitive performance (38.6%, 31.9%, and 54.8%, respectively). No mediations were observed for 4SKF. Conclusion: The negative association between fatness and cognitive performance is mitigated by the level of adolescents' physical fitness, mainly CRF and SAF. This mediation role seems to be more consistent with a central fat indicator even in the presence of school vulnerability. Strategies promoting physical fitness would reduce the cognitive gap in children and adolescents related to obesity and school vulnerability.
Full-text available
Objectives: To examine longitudinal (seven years) relationships among cardiorespiratory fitness (VO2peak), body fatness, and motor competence. Method: Data were collected as part of the Copenhagen School Child Intervention Study (CoSCIS). Body fatness was assessed by the sum of four skinfolds. VO2peak was measured directly in a continuous running protocol. Motor competence was assessed using the Körperkoordinationtest für Kinder. This study used multilevel linear mixed models to evaluate the reciprocal longitudinal association between body fatness, VO2peak, and motor competence. All regressions were stratified by sex and adjusted by intervention and pubertal status. All variable coefficients were standardized. Results: A reciprocal relationship was observed between children's motor competence with body fatness and VO2peak at the seven-year follow-up (6-13 years of age). Children with higher motor competence at baseline had a lower risk of having higher body fatness (βboys=-0.45, 95% CI: -0.52 to -0.38; βgirls=-0.35 Z-scores, 95% CI: -0.42 to -0.28) and higher VO2peak (βboys=0.34, 95% CI: 0.27-0.40; βgirls=0.27 Z-scores, 95% CI: 0.20-0.33) during childhood. Alternatively, higher body fatness or lower levels of VO2peak at baseline were associated with lower motor competence during childhood. Conclusions: These data suggest motor competence, body fatness, and VO2peak demonstrate reciprocal relationships across childhood (6-13 years of age). Interventions addressing motor competence, cardiorespiratory fitness, and body fatness in early childhood are recommended, as intervention effects are likely to be enhanced because of the mutual reciprocal associations between these three variables.
Full-text available
Purpose: The purpose of this study was to examine how regular participation in organized and unorganized PA affected the development of adolescents' CRF (peak oxygen consumption [VO2peak]), when controlled for sex interaction. Method: Data on direct measures of VO2peak and participation in organized PA among adolescents organized into 3 groups (participation in organized sport, participation in unorganized PA, and no weekly PA) were collected from 76 students (39 boys and 37 girls), when they were aged 14 and 19 years old. Results: Statistically significant differences were found between VO2peak values in the 3 groups at both 14 years of age, F(2, 73) = 7.16, p < .05, ƞ2 = .170, and 19 years of age, F(2, 73) = 14.00, p < .05, ƞ2 = .300, independent of sex at both 14 and 19 years of age, F(2, 73) = 0.05, p > .05, ƞ2 = .02, and F(2, 73) = 0.05, p > .05, ƞ2 = .00. Adolescents participating in organized sport also had statistically significantly higher VO2peak values than adolescents participating in unorganized PA and those with no weekly PA, at both 14 and 19 years of age. Conclusion: From a health perspective, in terms of CRF, the findings highlight the importance of encouraging adolescents to participate in organized sport and to refrain from dropping out of organized sport programs.
Full-text available
Objective: To investigate 1) differences in cardiometabolic risk and HOMA of insulin resistance (HOMA-IR) across BMI categories (underweight to morbid obesity), 2) whether fit children have lower cardiometabolic risk/HOMA-IR than unfit children in each BMI category, and 3) differences in cardiometabolic risk/HOMA-IR in normal-weight unfit children and obese fit children. Research design and methods: A pooled study including cross-sectional data from three projects (n = 1,247 children aged 8-11 years). Cardiometabolic risk was assessed using the sum of the sex- and age-specific z scores for triglycerides, HDL cholesterol, glucose, and the average of systolic and diastolic blood pressure and HOMA-IR. Results: A significant linear association was observed between the risk score and BMI categories (P trend ≤0.001), with every incremental rise in BMI category being associated with a 0.5 SD higher risk score (standardized β = 0.474, P < 0.001). A trend was found showing that as BMI categories rose, cardiorespiratory fitness (CRF) attenuated the risk score, with the biggest differences observed in the most obese children (-0.8 SD); however, this attenuation was significant only in mild obesity (-0.2 SD, P = 0.048). Normal-weight unfit children had a significantly lower risk score than obese fit children (P < 0.001); however, a significant reduction in the risk score was found in obese fit compared with unfit children (-0.4 SD, P = 0.027). Similar results were obtained for HOMA-IR. Conclusions: As BMI categories rose so did cardiometabolic risk and HOMA-IR, which highlights the need for obesity prevention/treatment programs in childhood. Furthermore, CRF may play an important role in lowering the risk of cardiometabolic diseases in obese children.
Full-text available
Aim: We investigated the longitudinal associations among physical activity (PA), motor competence (MC), cardiorespiratory fitness (VO2peak ) and body fatness across seven years, and also analyzed the possible mediation effects of PA, MC and VO2peak on the relationships with body fatness. Materials and methods: This was a seven-year longitudinal study with three measuring points (mean ages [in years] and respective sample size: 6.75 ±0.37, n=696; 9.59 ±1.07, n=617; 13.35 ±0.34, n=513). PA (moderate-to-vigorous PA - MVPA and vigorous PA - VPA) was monitored using accelerometers. MC was assessed by the 'Körperkoordinationstest für Kinder - KTK' test battery. VO2peak was evaluated using a continuous running protocol until exhaustion. Body fatness was determined by the sum of four skinfolds. Structural equation modeling was performed to evaluate the longitudinal associations among PA, MC, VO2peak and body fatness and the potential mediation effects of PA, MC and VO2peak . All coefficients presented were standardized (z-scores). Results: MC and VO2peak directly influenced the development of body fatness, and VO2peak mediated the associations between MVPA, VPA, MC and body fatness. MC also mediated the associations between MVPA, VPA and body fatness. In addition, VO2peak had the largest total association with body fatness (β= -0.431; p<0.05), followed by MC (β= -0.369; p<0.05) and VPA (β= -0.112; p<0.05). Conclusion: Since PA, MC and VO2peak exhibited longitudinal association with body fatness, it seems logical that interventions should strive to promote the development of fitness and MC through developmentally appropriate physical activities, as the synergistic interactions of all three variables impacted body fatness. This article is protected by copyright. All rights reserved.
Objectives: To examine the relationship between a battery of obesity indicators and physical fitness components with academic performance in children and to explore the combined and mediation role of the physical fitness components in the relationship between obesity and academic performance in children. Study design: A cross-sectional study including data from 250 Spanish schoolchildren (Balearic Islands) between 10 and 12 years of age (mean age, 10.98 ± 0.76 years) was conducted. Obesity measures (body mass index, body fat, waist circumference, hip circumference, and waist-to-height ratio), physical fitness components (cardiorespiratory fitness, muscular fitness, and speed-agility), and academic performance (Spanish language, Catalan language, English language, natural sciences, social sciences, arts, physical education, religion, and grade point average [GPA]) were collected. Results: All obesity measures were negatively related to at least 3 of the 10 academic indicators, including GPA (β range, -0.135 to -0.229; all P < .05). Cardiorespiratory fitness and speed-agility were positively related to all academic indicators (β range, 0.182 to 0.350; all P < .046) and muscular fitness with 3 academic indicators (β range, 0.143 to 0.253; all P < .039). Children considered as fit had better academic performance than their unfit peers (score +0.75; P = .001). The association between body mass index and GPA was mediated by cardiorespiratory fitness and speed-agility. Conclusions: This investigation contributes to the current knowledge by adding evidence about the crucial role of physical fitness in terms of academic performance rather than obesity status, suggesting that physical fitness may ameliorate the negative influence of obesity on academic performance.
Objective The early identification of predictors related to cardiovascular disease risk factor clustering (CVD-RFC) can help prevent chronic disease. We aimed to identify the risk factors for CVD-RFC in adolescents. Methods A prospective longitudinal cohort study design was used to obtain data included in these analyses from school-aged children who participated in the Korean Child-Adolescent Study 2008–2014. A total of 1309 children aged 6–15 years were enrolled. We compared the participants based on the presence or absence of CVD-RFC and examined the cumulative incidence of CVD-RFC. Results Of the total 1309 children, 410 (31.32%) had CVD-RFC in adolescence. A higher average household income ≥3 million Korean Republic won (KRW)/month (3–5 million KRW/month: HR 0.75 (95% CI 0.58 to 0.97); ≥5 million KRW/month: HR 0.58 (95% CI 0.44 to 0.77)) was associated with a lower CVD-RFC incidence, while the presence of parental CVD history (HR 1.28 (95% CI 1.04 to 1.57)), overweight or obesity (HR 3.83 (95% CI 3.05 to 4.80)) and shorter sleep duration of 8–9 hour/day (HR 1.80 (95% CI 1.05 to 3.07)) and <8 hour/day (HR 1.93 (95% CI 1.11 to 3.34)) had higher CVD-RFC incidences. Conclusions Obesity in childhood, short sleep duration and parental factors such as low socioeconomic status and parental history of CVD are significant risk factors for the development of CVD-RFC in adolescents. Efforts to create awareness regarding sufficient sleep duration in children via intervention programmes targeting cardiometabolic health in children and special attention to lifestyle modifications and socioeconomic components of the family should be considered.
Objective: To examine the association between cardiorespiratory fitness (CRF) at baseline and cardiovascular disease (CVD) risk in 6- to 10-year-olds (cross-sectional) and 2 years later (8- to 12-year-olds [longitudinal]) and whether changes with age in CRF are associated with CVD risk in children aged 8 to 12 years. Patients and methods: Spanish primary schoolchildren (n=236) aged 6 to 10 years participated at baseline. Of the 23 participating primary schools, 22% (n=5) were private schools and 78% (n=18) were public schools. The dropout rate at 2-year follow-up was 9.7% (n=23). The 20-m shuttle run test was used to estimate CRF. The CVD risk score was computed as the mean of 5 CVD risk factor standardized scores: sum of 2 skinfolds, systolic blood pressure, insulin/glucose, triglycerides, and total cholesterol/high-density lipoprotein cholesterol. Results: At baseline, CRF was inversely associated with single CVD risk factors (all P<.05) and CVD risk score at baseline and follow-up (P<.001). Cardiorespiratory fitness cutoff points of 39.0 mL/kg per minute or greater in boys and 37.5 mL/kg per minute or greater in girls are discriminative to identify CVD risk in childhood (area under the curve, >0.85; P<.001) and to predict CVD risk 2 years later (P=.004). Persistent low CRF or the decline of CRF from 6-10 to 8-12 years of age is associated with increased CVD risk at age 8 to 12 years (P<.001). Conclusion: During childhood, CRF is a strong predictor of CVD risk and should be monitored to identify children with potential CVD risk.
Childhood obesity predicts the risk of adult adiposity, which is associated with the earlier onset of cardiovascular disease [adult atherosclerotic cardiovascular disease, ACVD: hypertension, increased carotid intima media thickness (CIMT) stroke, ischemic heart disease (IHD)] and dysglycaemia. Because it is not known whether childhood obesity contributes to these diseases, we conducted a systematic review of studies that examine the ability of measures of obesity in childhood to predict dysglycaemia and ACVD. Data sources were Web of Science, MEDLINE, PubMed, CINAHL, Cochrane, SCOPUS, ProQuest and reference lists. Studies measuring body mass index (BMI), skin fold thickness and waist circumference were selected; of 1,954 studies, 18 met study criteria. Childhood BMI predicted CIMT: odds ratio (OR), 3.39 (95% confidence interval (CI), 2.02 to 5.67, P < 0.001) and risk of impaired glucose tolerance in adulthood, but its ability to predict ACVD events (stroke, IHD; OR, 1.04; 95% CI, 1.02 to 1.07; P < 0.001) and hypertension (OR, 1.17, 95% CI 1.06 to 1.27, P = 0.003) was weak-moderate. Body mass index was not predictive of systolic BP (r -0.57, P = 0.08) and weakly predicted diastolic BP (r 0.21, P = 0.002). Skin fold thickness in childhood weakly predicted CIMT in female adults only (rs 0.09, P < 0.05). Childhood BMI predicts the risk of dysglycaemia and abnormal CIMT in adulthood, but its ability to predict hypertension and ACVD events was weak and moderate, respectively. Skin fold thickness was a weak predictor of CIMT in female adults.
Background and Aims: Studies in the paediatric population have shown inconsistent associations between cardiorespiratory fitness and inflammation independently of adiposity. The purpose of this study was (i) to analyse the combined association of cardiorespiratory fitness and adiposity with high-sensitivity C-reactive protein (hs-CRP), and (ii) to determine whether adiposity acts as a mediator on the association between cardiorespiratory fitness and hs-CRP in children and adolescents. Methods and Results: This cross-sectional study included 935 (54.7% girls) healthy children and adolescents from Bogotá, Colombia. The 20 m shuttle run test was used to estimate cardiorespiratory fitness. We assessed the following adiposity parameters: body mass index, waist circumference, and fat mass index and the sum of subscapular and triceps skinfold thickness. High sensitivity assays were used to obtain hs-CRP. Linear regression models were fitted for mediation analyses examined whether the association between cardiorespiratory fitness and hs-CRP was mediated by each of adiposity parameters according to Baron and Kenny procedures. Lower levels of hs-CRP were associated with the best schoolchildren profiles (high cardiorespiratory fitness + low adiposity) (p for trend <0.001 in the four adiposity parameters), compared with unfit and overweight (low cardiorespiratory fitness + high adiposity) counterparts. Linear regression models suggest a full mediation of adiposity on the association between cardiorespiratory fitness and hs-CRP levels. Conclusions: Our findings seem to emphasize the importance of obesity prevention in childhood, suggesting that having high levels of cardiorespiratory fitness may not counteract the negative consequences ascribed to adiposity on hs-CRP.