“Health and Physical Activity in children – new knowledge and new directions”

1. “Health and Physical Activity in children – new knowledge and new directions” Karsten Froberg, Head of RICH Center Department of Sports Science & ClinicalBiomechanics University of Southern Denmark

2. Main objectives • Understandingthe physical and social benefits of physicalactivity and fitness • Developingbettermethods for measuring PA and health determinants • 25 employes – incuding 14 PhD students • 185 scientificpublications in 5 years Supported by the TrygFonden Foundation, The Danish Agency for Science, Technology and Innovation, The Health Foundation, The Heart Foundation, The Nordea Foundation, Team Denmark, The IMK Foundation, The Region of Southern Denmark, The Foundation of BUPL (Union for Pedagogues), the Communities of Vejle and Odense and the University of Southern Denmark with around 7 million Euro in the last 5 years. ENSSEE, Groningen, October 2013

3. HEALTHAND LIFESTYLE Risk factors underlying Chronic Deseases are partly nonmodifiable, (age, sex, genetic susceptibility), and partly modifiable, related to biological factors (overweight, hypertension, dyslipidemias, hyperinsulinemia), and particularly to lifestyle (tobacco, diet, alcohol use and physical (in)activity). It is on the latter that public health policies are mainly based, focusing on education to healthy lifestyle at all ages and particularly from early childhood. ENSSEE, Groningen, October 2013

4. The human genome Sedentary lifestyle: Does not maintain required metabolic demands and muscle loading Human genome: evolved to support a physically active lifestyle Genome unchanged in past 10,000 years Result in: Insulin resistance in skeletal muscles Weak skeletal muscles Coronary artery disease Hypertension Some cancers Type 2 diabetes Depression Physical frailty Osteoporosis Booth et al, 2002 ENSSEE, Groningen, October 2013

5. The European Youth Heart Study - cardiovascular disease risk factors in children: rationale, aims, study design and validation of methods. Chris Riddoch, Dawn Edwards, Angie Page, Karsten Froberg, Sigmund A. Anderssen, Niels Wedderkopp, SorenBrage, Ashley Cooper, Luis Sardinha, MaarikeHarro, Lena KlassonHeggebø, Willem van Mechelen, Colin Boreham, Ulf Ekelund, Lars Bo Andersen. Journal of Physical Activity and Health, 2005, 2, 115-129 ENSSEE, Groningen, October 2013

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7. Things wearestudyingin EYHS/RICH Environment Family/peers influence Socio-economical status Culture Leisure time possibilities. Personal Age Gender Birthweight Genotype Selfefficacy Stress Barrieres etc.. Lifestyle Physical (in)activity Nutrition, smoking and alcoholintake Back problems Bone health Injuries Muscle strength Arterial stiffness Cognition Physiologicalriskfactores Cardiorespiratory fitness Bloodpressure Insulin/glucose Cholesterol and triglycerides Overweigth and fatness ENSSEE, Groningen, October 2013

8. Study locations Iceland 6yr f.u. Oslo+country 6yr f.u. Odense 6 & 12 yrf.u. Tartu 6 yrf.u. Cambridge Bristol Amsterdam Vienna pilot Madrid Lisbon Tirana pilot Madeira 6and 12 yrf.u. ENSSEE, Groningen, October 2013

9. Methods • Computerised questionnaire (psychosocial and environmental factors) • Parental questionnaire (self-reported health status, SES, family history etc.) • Biochemistry (fasting blood samples) • Anthropometry (height, weight, waist and hip circumference) • Body composition (skinfolds) • Resting blood pressure • Sexual maturity (Tanner stage) • Aerobic fitness (maximal power output on bicycle, W/kg) • Physical activity (Actigraph) • Diet (24-hour assisted recall) ENSSEE, Groningen, October 2013

10. Denmark Invited: n=771 Invited: n=658 EYHS-1 1997/98 9-year olds 15-year olds Invited n=709 EYHS-2 2003/04 9-year olds 15-year olds EYHS-3 2009/10 15-year olds 21-year olds 27-year olds ENSSEE, Groningen, October 2013

11. Someresults Cross-sectional data ENSSEE, Groningen, October 2013

12. Metabolicrisk score • (mean of SD-score (Z-score)) • Systolic blod pressure • Triglycerides in blood • Total cholesterol/HDL ratio • Insulin sensitivity • Fatness– (Sum of four skinfolds/waistcircumference/BMI/Pondoral Index/DEXA) • Cardiovascular fitness ENSSEE, Groningen, October 2013

13. Cardiorespiratory fitness is strongly associated to clustering of CVD risk factors in children and youth. - The findings were fairly similar between countries (in different geographical regions) and between sex and age groups. Anderssen et.al. EurJ CardiovascPrevRehabil. 2007 Aug;14(4):526-31 ENSSEE, Groningen, October 2013

14. Odds ratio in quartilesof fitness for riskfactoresin 6-7 y and 9-10 y children (the same children) Bugge et.al. Pediatr Res. 2013 Feb;73(2):245-9 ENSSEE, Groningen, October 2013

15. 0.15 0.5 Aerobic fitness Aerobic fitness Physical Activity 0.4 Physical Activity 0.1 0.3 0.05 0.2 Clustered risk (Z-score) 0 Clustered risk (non-Ob) 0.1 0 -0.05 -0.1 -0.1 -0.2 -0.15 -0.3 -0.2 -0.4 Z-score includingwaistcircum. Z-score excludingwaistcircum. Leastfit/active Most fit/active Leastfit/active Most fit/active CRF; P for trend < 0.0001 PA; P for trend = 0.015 CRF; P for trend = 0.06 PA; P for trend < 0.0001 Adjusted for age group, gender and studylocation Adjusted for age group, gender, studylocation and waistcircumference (Ekelund et.al. Diabetologia, 2007;50:1832-40) ENSSEE, Groningen, October 2013

16. CONCLUSIONS/INTERPRETATION: • PA and CRF are separately and independently associated with individual and clustered metabolic risk factors in children. • The association between CRF and clustered risk is partly mediated or confounded by adiposity • The association between activity and clustered risk is independent of adiposity. • The results suggest that fitness and activity affect metabolic risk through different pathways ENSSEE, Groningen, October 2013

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19. The results showed that muscle fitness and cardiorespiratory fitness were independently associated with metabolic risk in youth. Steene-Johannessen J et.al. Med Sci Sports Exerc. 2009 Jul;41(7):1361-7 ENSSEE, Groningen, October 2013

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21. The European Youth Heart Study: analysis based on Danish, Estonian and Portuguese data Metabolic Z-’health-score’ Blood Pressure Triglyceride Total cholesterol / HDL ratio Insulin sensitivity Fat mass Cardio-respiratory fitness Data adjusted for age and gender, in continuous analysis ENSSEE, Groningen, October 2013

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24. Interpretation • Current guidelines of at least 1 hour per day of physical activity of at least moderate intensity may be an underestimation of the activity necessary to prevent clustering of CVD risk factors in children. ENSSEE, Groningen, October 2013

25. ROC curve for boys Clinical Cutpoints for CV Fitness • Receiver operating characteristic (ROC) • AdegboyeAR et.al. BrJ Sports Med. 2011 Jul;45(9):722-8 • The European Youth Heart Study • 43 - 46 ml.kg-1.min-1 (9 and 15 y boys) • 34 - 37 ml.kg-1.min-1 (9 and 15 y girls) • Welk GJ et.al. Am J Prev Med.2011; 41(4 Suppl 2):S111-6 • The National Health and Nutrition Examination Survey • 40-44 ml/kg/min for boys (11-14 y) • 38-40 ml/kg/min for girls (11-14 y) ENSSEE, Groningen, October 2013

26. New prospective or longitudinal data Aim - To examine the association of isometric trunk muscle strength in youth with cardiovascular risk factors in young adulthood Aim -To examine the independent and combined association of isometric trunk muscle strength and cardiorespiratory fitness in youth with indices of insulin resistance and beta-cell function in young adulthood among Danish youth from EYHS. ENSSEE, Groningen, October 2013

27. Methods 14-16-year old 26-28-year old 9th grade pupils in Odense Municipality 9th grade pupils in Odense Municipality 1997-98 N=429 (65%) 2009-10 N=281 (43%) n=658 n=771 14-16-year old 20-22-year old 2003-04 N=444 (58%) 2009-10 N=369 (48%) ENSSEE, Groningen, October 2013

28. Methods Isometric muscle strength during maximal voluntary contraction (MVC) of abdominal and back muscles using a strain-gauge dynamometer Cardiorespiratoryfitness (CRP) • High test-retest reliability of these particular isometric strength measures (intraclass correlation coefficient>0.9) (Andersen et al. 1987, Essendrop et al. 2001) • Moderate- to strong correlation between isometric- and dynamic muscle strength(Juneja et al. 2010) Progressive maximal ergometer bicycle test (r=0.9 with VÓ2-max assessed directly, highly reproducible) Validation study used to estimate ml O2/min based on max watts at peak workload (Riddoch C et.al. Journal of Physical Activity and Health, 2005, 2, 115-129) Normalized to body mass (kg) ENSSEE, Groningen, October 2013

29. Methods Analytical strategy: Prospective analysis, multiple linear regression analysis including n=332 with complete data Waist circumference BMI Youth isometric muscle strength of the abdomen and back CVD risk factors in young adulthood Body mass index Waist circumference BP Triglycerides HDL Fasting glucose Age Gender Baseline levels of CVD risk factor Recruitment period Parental educational level Smoking status Family history of CVD Frequency of intake of soft drinks Frequency of intake of fruit and vegetables Television viewing Cardiorespiratory fitness ENSSEE, Groningen, October 2013

30. Results Multivariable adjusted incl. cardiorespiratory fitness MV adjustment for: Age at baseline, follow-up time, sex and recruitment period, TV watching, parental education level, smoking status, intake of soft drinks, fruit and vegetable intake and family history of CVD, cardiorespiratory fitness ENSSEE, Groningen, October 2013

31. Results Adjusted for: Age at baseline, follow-up time, sex and recruitment period, TV watching, parental education level, smoking status, intake of soft drinks, fruit and vegetable intake and family history of CVD, and cardiorespiratory fitness ENSSEE, Groningen, October 2013

32. Results Insulin sensitivity Multivariable adjustment (MV). Baseline levels of risk factor, age, sex, and recruitment period, television viewing, parental education level, smoking status, intake of soft drinks, fruit and vegetable intake, and family history of diabetes. ENSSEE, Groningen, October 2013

33. Conclusions • Greater isometric muscle strength of the abdomen and back in youth was associated with lower levels of CVD risk factors in young adulthood independent of cardiorespiratory fitness and other important determinant of CVD risk • Increasing muscle strength and Cardio-Respiratory Fitness should be targets in youth prevention strategies of insulin resistance and β-cell dysfunction. • Prolonged TV- and total screen time viewing during leisure time in adolescence, and increases in these behaviors, are associated with unfavorable levels of several cardiovascular risk factors in young adulthood. ENSSEE, Groningen, October 2013

34. Newestarticles Screen time viewing behaviors and isometrictrunkmusclestrength in youth. Grøntved A, et.al. Med Sci Sports Exerc. 2013 Oct;45(10) CONCLUSIONS Screen time use was inversely associated with isometric trunk muscle strength independent of CRF and other confounding factors Associations between objectly measured physical activity intensity in childhood (9-10 y) and measures of subclinical cardiovascular disease in adolescence (15-16 y): prospective observations from the European Youth Heart Study. Ried-Larsen M et.al. BrJ Sports Med. 2013 Apr 13. [Epubahead of print] CONCLUSIONS A high mean exposure to, or changes in, minutes spent at higher PA intensities across childhood was not associated to thicknessor stiffness in the carotid arteries in adolescence. But a high volume of vigorous PA across childhood is independently associated with lower metabolic cardio-vascular disease risk in adolescence. Moderate and vigorous physical activity from adolescence to adulthood and subclinical atherosclerosis in adulthood: prospective observations from the European Youth Heart Study.Ried-Larsen M et.al. BrJ Sports Med. 2013 Apr 13. [Epubahead of print] CONCLUSIONS: High mean exposure to moderate-and-vigorous PA levels and increases herein were independently associated with lower levels of carotid arterial stiffness in adulthood ENSSEE, Groningen, October 2013

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36. Wherearewegoing? ENSSEE, Groningen, October 2013

37. Is there a correlationbetweenphysical fitness/activity and cognition? ENSSEE, Groningen, October 2013

38. PNAS, Dec 2009, Vol. 106, 49 ENSSEE, Groningen, October 2013

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40. Twins ENSSEE, Groningen, October 2013

41. What is cognition? • Perception • Attention • Memory • Reasoning • Problem-solving Processing thoughts Learning new things, producing and understandinglanguage, math, decision making etc. ENSSEE, Groningen, October 2013

42. Where to ‘find’ it? ENSSEE, Groningen, October 2013

43. Executivefunctions (EF) • An umbrella term that includes the cognitive processes responsible for organizing and controlling goal-directed behavior (Banich, 2009) • Three fundamental components: Cognitiveflexibility Workingmemory Inhibition Miyake et al. 2000 ENSSEE, Groningen, October 2013

44. The effects of physical activity and exercise on brain-derived neurotrophicfactor (BDNF) in healthy humans: A review. Huang T, Larsen KT, Ried-Larsen M, Møller NC, Andersen LB. Centre of Research in Childhood Health, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. Most observational studies suggested an inverse relationship between the peripheral BDNF level and habitual physical activity or cardiorespiratory fitness. More research is needed to confirm the findings from the observational studies. ScandJ Med Sci Sports. 2013 Apr 22. [Epub ahead of print] ENSSEE, Groningen, October 2013

45. Learning throughMovement ENSSEE, Groningen, October 2013

46. Acknowledgement The Danish Council for Strategic Research The Danish Heart Foundation, The Danish Health Fund The TrygFond The Danish Council for Sports Research The University of Southern Denmark The Faculty of Health Sciences, SDU Thank you for listening ENSSEE, Groningen, October 2013