|Year : 2014 | Volume
| Issue : 2 | Page : 79-84
Comparison of cardiovascular fitness of children 13-16 years of age from rural and urban areas of Belgaum district: A cross sectional study
Arati Mahishale, Neha Kulkarni
Department of OBG Physiotherapy, KLEU Institute of Physiotherapy, Belgaum, Karnataka, India
|Date of Web Publication||20-May-2014|
KLEU Institute of Physiotherapy, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Objective: Low cardiovascular fitness (CVF) in children has been associated with increasing cardiovascular and metabolic risk in later life. CVF with respect to specific social and geographical factors such as rural and urban area of residence has not been addressed in developing countries. Various studies have been done in populations abroad to document varying and contradictory results. The present cross-sectional study was hence undertaken to compare the CVF of adolescents from rural and urban areas of Belgaum district. Materials and Methods: 305 children from secondary schools from rural and urban areas of Belgaum district were recruited through simple random sampling. The children underwent measurement for baseline parameters such as resting heart rate, blood pressure, skin fold thickness, height and weight. Questionnaire about their daily life-style parameters such as television watching, daily physical activity and mode of transport to school were recorded. Outcome measures included the beep test to evaluate CVF. Results: After data analysis, the rural group was found to have significantly higher values of maximal oxygen consumption when compared with their urban peers (P = 0.000). The rural children reported higher duration of daily physical activity and more use of active means of transport to school. Conclusion: The study concluded that rural children had higher CVF as compared to their urban counter parts.
Keywords: Adolescents, cardiovascular fitness, maximal oxygen consumption, rural, urban
|How to cite this article:|
Mahishale A, Kulkarni N. Comparison of cardiovascular fitness of children 13-16 years of age from rural and urban areas of Belgaum district: A cross sectional study. J Sci Soc 2014;41:79-84
|How to cite this URL:|
Mahishale A, Kulkarni N. Comparison of cardiovascular fitness of children 13-16 years of age from rural and urban areas of Belgaum district: A cross sectional study. J Sci Soc [serial online] 2014 [cited 2020 Aug 9];41:79-84. Available from: http://www.jscisociety.com/text.asp?2014/41/2/79/132828
| Introduction|| |
Howley and Franks define physical fitness as "a state of well-being with low risk of premature health problems and energy to participate in a variety of physical activity. It is the ability of the circulatory and respiratory systems to adjust to and recover from the effect of whole body exercise.  Cardiovascular fitness (CVF) is as a direct marker of physiologic status the level of which is associated with many health related outcomes.  High CVF during childhood and adolescence has been associated with a healthier cardiovascular profile during these years and also later in life.  Moreover, CVF seems to prevent premature mortality and it has also been associated with body fat, with features of metabolic syndrome and with arterial compliance in young population, which supports the concept that CVF may exert a protective effect on the cardio vascular system from an early age.  Furthermore recently CVF has been associated with better cognitive performance. 
Epidemiologists from the World Health Organization have been sounding an alarm on the rapidly rising burdens of cardiovascular disease in the last decade.  The reported prevalence of coronary heart disease (CHD) in adult surveys has risen 4 fold over the last 40 years to the present level of 10% and even in rural areas the prevalence has doubled over the past 30 years to the present level of 4%. The risk factors of CHD are also on the rise. India, already the diabetes capital of the world with 32 million diabetics' people, is projected to have 69.8 million diabetics in 2025. The count of hypertensive individuals is expected to rise from 118 million to 214 million by 2025.  Several factors appear likely to have contributed to the acceleration of coronary artery disease (CAD) epidemic in India in recent times. One of these is the confluence of both conventional risk factors such as hypertension, diabetes, hypercholesterolemia, smoking etc., which owe their origin to increasing western acculturation and non-conventional risk factors of genetic origin such as hyperinsulinemia, insulin resistance etc., in Indians with excess risk is seen in young Indians. 
Many of the risk factors for CAD appear to begin in childhood and youth. As many as 60% of children in the United States exhibit at least one modifiable adult risk factor for CAD disease by the age of 12. It has been shown that reduced CVF, low physical activity and an urban environment were independently associated with increased cardiovascular risk in children.  Low levels of physical activity and a sedentary life-style among children have been implicated in the development of cardiovascular disease, obesity, hypertension, type 2 diabetes and other chronic diseases later in life.
The importance of early interventions has prompted studies about physical fitness in Indian children. Although the associations between physical fitness and social factors such as gender and race/ethnicity have been widely examined, geographical factors have received less attention, especially in developing countries. The emphasis of researchers in India has remained mainly on the reporting of physical growth and development patterns among different populations inhabiting the country, as is evident from a large number of publications reported in the literature in the last 50 years. 
The census defined urban India as "all the places within the administrative limits of a municipal corporation, municipality, cantonment board etc., or have a population of at least 5000 and have a population density of at least 400/km 2 . Rural India, on the other hand, comprises all places that are not urban. Almost 72% of the Indian population is from the rural areas. The difference in the availability of numerous health care and development facilities in urban areas as compared to rural areas is quite evident. The difference in health related fitness needs to be seen. Better living conditions have been shown to offer a potential advantage for improved physical fitness in urban as compared to rural children, nevertheless, urban residence has been linked to sedentary life-style due to lack of adequate space for play, concerns for safety, automatic transportation and computerization of many activities. However, it is not entirely clear whether such factors can affect aspects of physical fitness. Contradictory reports have been published in relation to physical fitness parameters in children living in urban and rural settings. In some cases, no differences have been identified in a range of fitness between children from urban and rural areas.  Living in an urban area was shown to be independently associated with reduced cardio respiratory fitness, increased insulin resistance and the metabolic risk score.  In European countries no evidence was found that supports the widespread concept that urbanization affects the exercise fitness during growth. Children living in rural environment become socially isolated, adopt sedentary living habits which subsequently hamper the development of functional characteristics.  However, it remains to be seen whether these results would reflect among Indian rural and urban areas. Of the many factors affecting CVF, the effects of urbanization with its multifold benefits and adverse effects on the fitness of children needs to be seen. For public health strategies and preventive purposes it may be of benefit to have evidence based health criteria values of CVF in urban and rural children as there is a dearth of studies addressing these subpopulations in Indians. Hence, this study was undertaken with the primary objective of assessing the difference in CVF in urban and rural children of age 13 to 16 years from Belgaum district.
| Materials and methods|| |
A cross-sectional study.
Selection of participants
Primary data was collected from secondary schools from rural and urban areas of Belgaum district. Data was collected during the month from April 2010 to December 2010.
Sampling design and method
Schools were selected using a simple random sampling and the students were randomly picked up using lottery method.
Boys and girls in the age group of 13-16 years and who were willing to participate in the study were included for the study.
Children with known cardiovascular problems, orthopedic problems, history of asthma and those unable to understand commands and carry out instructions were excluded from the study.
| Procedure|| |
Ethical clearance was obtained from the institutional ethical review committee. The school authorities were approached and the procedure and purpose was explained. A total of 9 schools were selected for the study out of which 305 students were recruited using lottery method. There were 156 students from the rural area forming Group A and 149 from the urban area forming Group B. After obtaining permission for conducting the study from the school authorities, the test and its purpose was verbally explained to the students in their vernacular language. Children who fulfilled the inclusion exclusion criteria were then given informed consents to be signed from their parents and themselves and only those with consent were recruited for the study.
Baseline measurements were taken for the following parameters - weight in kg using standardized bathroom weighing scale, height was measured using a measuring tape stuck on a wall. Skin fold thickness was taken using calipers at two sites - biceps and triceps on the left side. Resting heart rate (HR) was measured manually using the radial pulse and blood pressure was measured using a digital wrist monitor (OMRON REM 1). Data on life-style parameters such as watching television per daily in hours, physical activity in daily hours and type of diet preferred whether vegetarian or non-vegetarian was noted. The mode of transport to school was also recorded. After the baseline measurements the children underwent testing for CVF using a standardized field test as the primary outcome measure.
Outcome measure: 20 m shuttle test
This test is made up of 23 levels, each level lasting approximately 1 min. Each level will comprise of a series of 20 m shuttles where the starting speed will be 8.5 km/h and will increase by 0.5 km/h at each level. On the laptop, software was used where a single beep would indicate the end of a shuttle and 3 beeps indicated the start of the next level. A 20 m section of ground was measured and marked with a marker. The participant was taught a warm up program before starting the test. The participant placed one foot on or beyond the 20 foot marker at the end of each shuttle. If the participant arrived at the end of the shuttle before the beep he/she would wait for the next beep and then resume running. The participant would keep running for as long as possible until he or she can no longer keep up with the speed set up by the laptop at which point he/she will voluntarily withdraw. If he/she has failed to reach the end of the shuttle before the beep they were allowed 2 or 3 further shuttles to attempt to regain the required pace before being withdrawn. The level and number of shuttles completed at that level by the student were recorded. At the end of the test, the participants conducted a cool down program. The maximal oxygen consumption (VO 2 max) was estimated using the predictive equations which were then compared statistically. This test has good validity and reliability. 
| Results|| |
Data was analyzed in terms of age, gender, baseline parameters - body mass index (BMI), resting HR, blood pressure and sum of skin fold thickness taken at two sites of the two groups. CVF was analyzed using estimated VO 2 max from the shuttle run test results.
Paired and unpaired t-tests were used for calculating the difference in mean values between the two groups. Chi-squared tests were used for calculating the distribution of variables in the groups. The significance level was set at P < 0.05.
The mean age of participants in Group A was 14.5 ± 0.83 years and Group B was14.006 ± 0.88 which were well-matched [Table 1]. Group A had 99 males and 57 females while Group B had 52 males and 97 females. Here Chi-square analysis revealed statistically significant difference between gender distribution (P = 0.000) [Table 2].
Among the baseline parameters assessed, significant differences were seen in the BMI of both the groups with the urban group (Group B) showing slightly higher scores in mean value = 17.80 ± 2.81 kg/m 2 . Sum of skin fold thickness at two different sites were compared between the two groups, mean of which was 20.30 ± 5.85 mm in Group B and 16.74 ± 5.81 mm in Group A. t-test values revealed a statistically significant difference with a P value of 0.000 [Table 3]. Differences in the blood pressure and resting HR were not significant with P values of 0.971 and 0.588 respectively.
Certain other variables were also studied in conjunction namely self-reports about the television viewing, food habits, daily physical activity and mode of transport to school were also studied. Significant differences were seen in the daily physical activity with rural children having a mean daily physical activity of 2.60 ± 1.35 h and urban children had 1.49 ± 0.84 h. Television viewing and food habits were not statistically significant between groups. Children from rural area also were found to have significant use of active means of transport such as cycling and walking with 96% either walking or cycling to school as compared to 77% in the urban areas [Table 4], [Table 5] and Graph 1 [Additional file 1], Graph 2 [Additional file 2].
Estimated VO 2 max from the shuttle run test showed significant difference between the two groups. Mean VO 2 max for the rural group was 31.62 ± 6.88 and urban Group B was 27.44 ± 5.13. With t value of 6.148 and P = 0.000 [Table 6]. Mean VO 2 max of the males in the rural group was 35. 20 ± 5.06 ml/kg/min and 31.56 ± 4.57 ml/kg/min. Mean VO 2 max of the urban group was 25.24 ± 3.79 ml/kg/min and females in the rural group was 25.39 ± 3.59 ml/kg/min [Table 7] and Graph 3 [Additional file 3].
| Discussion|| |
The aim of this study was to compare the CVF of children from rural and urban areas of Belgaum district. Results show a clear trend towards the rural children being more fit in terms of CVF as compared to urban children. These results are in agreement with Kriemler et al. who has shown that an urban environment is associated with lesser physical activity and lower values of CVF.  Furthermore in agreement are the results of another study conducted in Turkey where the urban children were found to be more inactive and obese.  However, several other studies have contradictory results. Studies conducted across four other European countries have shown that rural children have lower CVF and increased prevalence of cardiovascular risk factors  Various explanatory reasons have been cited for the urban children performing better such as children having a better socioeconomic status and parents with a better educational background. Urban families also may have better access to public health and recreational facilities and may be able to exploit the facilities to their advantage. Also 1 urban children are exposed to better nutrition, medical care and treatment, physical education and sports. , However, results from the present study show that rural children have better CVF than urban children. The above findings may have multiple causative explanations. They may be because of difference in various lifestyle parameters such as the number of children using active means of transport to school. In the rural areas, 96% of children either walked or cycled to school while in the urban areas around 77% children used similar means of active transport. Cooper et al. conducted a study where they showed that students who used active means of transport such as cycling to school had higher CVF and were 5 times more likely to fall in the top quartiles of health related fitness.  Another factor associated with low CVF is physical inactivity.  Self-reported physical activity in the rural children of the sample was 1 h more than the urban counterparts which may have a role in determining the higher fitness levels. Studies have shown physical fitness to be mainly determined by the level of physical activity. Although sedentary life-styles such as increased television watching have been associated with increased cardiovascular risk factors, the present study showed no difference in the television watching habits of rural and urban children.  On the other hand, CVF of the children taken together (mean of rural and urban) was on the lower side as compared with normative data. The mean VO 2 max values of the female children were 27.44 ± 5.13 while the males had a value of 31.62 ± 6.58, which signifies that males have higher values in agreement with the present literature.  There were more number of males in the rural population which might have a bias on the total mean aerobic capacity of the rural sample presented here. However, the rural boys had a mean VO 2 max of 35.20 ml/kg/min which was higher than the mean VO 2 max of the urban boys which was 31.56 ml/kg/min. The girls from rural and urban area compared separately showed no difference in mean VO 2 max. However, based on the expert judgment European group pediatric work physiology, a VO 2 max of ≥35 ml/kg/min and 40 ml/kg/min for girls and boys respectively is taken as the health cut off value.  Considering these cut off values, children from Belgaum district fall below the expected healthy ranges of CVF. This value may be due to the lack of awareness among parents, school authorities and children of the importance of physical fitness, activity and cardio vascular risk profile. There is also an increasing trend towards better academic performance due to which physical activity may have been reduced. The results from the present study share a similarity with previous findings among Indian female students where most of the students had poor CVF in terms of physical fitness index measured by Queen's College step test.  These results also reflect on decreased cardio vascular health of children from Belgaum district. Low cardio vascular fitness is an important component of the cardio vascular risk factors for adult CHD as shown by Hofman and Walter.  In a longitudinal study they concluded that unfavorable long term changes in physical conditions may be related to unfavorable changes in blood pressure and blood lipids.
In this study, no significant difference was found between the dietary habits of the children with relation to consumption of vegetarian as compared to an omnivorous diet. There have been reports however of a vegetarian diet to have a beneficial effect on various cardiovascular risk factors in adults such as blood lipids and blood pressure. , Also adolescents consuming predominantly vegetarian foods show significantly better scores on markers of cardiovascular health, including, BMI and waist circumference.  The results of the study stress the need for an ongoing and regular fitness evaluation in school from both rural and urban areas. It can also help in preventive strategies to address cardio vascular risk through one of the most easily modifiable parameters that is cardio vascular fitness training. Due to non-homogenous nature of the groups for sex and age distribution the results may have been biased towards favoring the rural group. Better standardization would have increased the strength of the findings. The study was conducted in one district and hence cannot be generalized to a larger population. Further studies addressing a larger geographical area and a homogenous population will be useful. Objective measures of physical activity such as accelerometers and other relevant data such as social economic status and family background, nutritional data etc., can help better in the formation of preventive strategies.
| Conclusion|| |
The study concluded that there exists a clear, statistically significant difference in the CVF of children 13 to 16 years of age from rural and urban areas of Belgaum district with the rural children having better CVF as compared to their urban counter parts.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]