Mayo Clinic Proceedings Home

Cardiorespiratory Fitness Cutoff Points for Early Detection of Present and Future Cardiovascular Risk in Children

A 2-Year Follow-up Study
Published:November 17, 2017DOI:



      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.


      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).


      During childhood, CRF is a strong predictor of CVD risk and should be monitored to identify children with potential CVD risk.

      Abbreviations and Acronyms:

      AUC (area under the curve), CRF (cardiorespiratory fitness), CVD (cardiovascular disease), HDL-C (high-density lipoprotein cholesterol), HOMA-IR (homeostasis model assessment for insulin resistance), OR (odds ratio), SBP (systolic blood pressure), TC (total cholesterol), TG (triglycerides), VO2max (maximum oxygen consumption)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Smith Jr., S.C.
        • Jackson R.
        • Pearson T.A.
        • et al.
        Principles for national and regional guidelines on cardiovascular disease prevention: a scientific statement from the World Heart and Stroke Forum.
        Circulation. 2004; 109: 3112-3121
        • Lim S.S.
        • Vos T.
        • Flaxman A.D.
        • et al.
        A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2224-2260
        • McGill Jr., H.C.
        • McMahan C.A.
        • Herderick E.E.
        • Malcom G.T.
        • Tracy R.E.
        • Strong J.P.
        Origin of atherosclerosis in childhood and adolescence.
        Am J Clin Nutr. 2000; 72: 1307S-1315S
        • Strong J.P.
        • Malcom G.T.
        • Newman III, W.P.
        • Oalmann M.C.
        Early lesions of atherosclerosis in childhood and youth: natural history and risk factors.
        J Am Coll Nutr. 1992; 11: 51S-54S
        • Berenson G.S.
        • Srinivasan S.R.
        • Bao W.
        • Newman III, W.P.
        • Tracy R.E.
        • Wattigney W.A.
        Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults: the Bogalusa Heart Study.
        N Engl J Med. 1998; 338: 1650-1656
        • Andersen L.B.
        • Harro M.
        • Sardinha L.B.
        • et al.
        Physical activity and clustered cardiovascular risk in children: a cross-sectional study (The European Youth Heart Study).
        Lancet. 2006; 368: 299-304
        • Andersen L.B.
        • Bugge A.
        • Dencker M.
        • Eiberg S.
        • El-Naaman B.
        The association between physical activity, physical fitness and development of metabolic disorders.
        Int J Pediatr Obes. 2011; 6: 29-34
        • Ortega F.B.
        • Ruiz J.R.
        • Castillo M.J.
        • Sjostrom M.
        Physical fitness in childhood and adolescence: a powerful marker of health.
        Int J Obes (Lond). 2008; 32: 1-11
        • Ruiz J.R.
        • Castro-Pinero J.
        • Artero E.G.
        • et al.
        Predictive validity of health-related fitness in youth: a systematic review.
        Br J Sports Med. 2009; 43: 909-923
        • Kvaavik E.
        • Klepp K.I.
        • Tell G.S.
        • Meyer H.E.
        • Batty G.D.
        Physical fitness and physical activity at age 13 years as predictors of cardiovascular disease risk factors at ages 15, 25, 33, and 40 years: extended follow-up of the Oslo Youth Study.
        Pediatrics. 2009; 123: e80-e86
        • Ruiz J.R.
        • Huybrechts I.
        • Cuenca-Garcia M.
        • et al.
        Cardiorespiratory fitness and ideal cardiovascular health in European adolescents.
        Heart. 2015; 101: 766-773
      1. Ruiz JR, Cavero-Redondo I, Ortega FB, Welk GJ, Andersen LB, Martinez-Vizcaino V. Cardiorespiratory fitness cut points to avoid cardiovascular disease risk in children and adolescents; what level of fitness should raise a red flag? a systematic review and meta-analysis [published online September 26, 2016]. Br J Sports Med.

        • Castro-Pinero J.
        • Carbonell-Baeza A.
        • Martinez-Gomez D.
        • et al.
        Follow-up in healthy schoolchildren and in adolescents with Down syndrome: psycho-environmental and genetic determinants of physical activity and its impact on fitness, cardiovascular diseases, inflammatory biomarkers and mental health; the UP&DOWN study.
        BMC Public Health. 2014; 14: 400
        • Tanner J.
        Growth at Adolescence.
        Oxford, UK, Blackwell1962
        • Lohman T.G.
        • Roche A.F.
        • Matorell R.
        Anthropometric Standardization Reference Manual.
        Human Kinetics, Champaign, IL1991
        • Topouchian J.A.
        • El Assaad M.A.
        • Orobinskaia L.V.
        • El Feghali R.N.
        • Asmar R.G.
        Validation of two automatic devices for self-measurement of blood pressure according to the International Protocol of the European Society of Hypertension: the Omron M6 (HEM-7001-E) and the Omron R7 (HEM 637-IT).
        Blood Press Monit. 2006; 11: 165-171
        • Matthews D.R.
        • Hosker J.P.
        • Rudenski A.S.
        • Naylor B.A.
        • Treacher D.F.
        • Turner R.C.
        Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man.
        Diabetologia. 1985; 28: 412-419
        • Ruiz J.R.
        • Castro-Pinero J.
        • Espana-Romero V.
        • et al.
        Field-based fitness assessment in young people: the ALPHA health-related fitness test battery for children and adolescents.
        Br J Sports Med. 2011; 45: 518-524
        • Ruiz J.R.
        • Espana Romero V.
        • Castro Pinero J.
        • et al.
        ALPHA-fitness test battery: health-related field-based fitness tests assessment in children and adolescents.
        Nutr Hosp. 2011; 26 ([in Spanish]): 1210-1214
        • Castro-Pinero J.
        • Artero E.G.
        • Espana-Romero V.
        • et al.
        Criterion-related validity of field-based fitness tests in youth: a systematic review.
        Br J Sports Med. 2009; 44: 934-943
        • Artero E.G.
        • Espana-Romero V.
        • Castro-Pinero J.
        • et al.
        Reliability of field-based fitness tests in youth.
        Int J Sports Med. 2011; 32: 159-169
        • Leger L.A.
        • Mercier D.
        • Gadoury C.
        • Lambert J.
        The multistage 20 metre shuttle run test for aerobic fitness.
        J Sports Sci. 1988; 6: 93-101
        • Lobelo F.
        • Pate R.R.
        • Dowda M.
        • Liese A.D.
        • Ruiz J.R.
        Validity of cardiorespiratory fitness criterion-referenced standards for adolescents.
        Med Sci Sports Exerc. 2009; 41: 1222-1229
        • Zweig M.H.
        • Campbell G.
        Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine.
        Clin Chem. 1993; 39: 561-577
        • Bugge A.
        • El-Naaman B.
        • McMurray R.G.
        • Froberg K.
        • Andersen L.B.
        Tracking of clustered cardiovascular disease risk factors from childhood to adolescence.
        Pediatr Res. 2013; 73: 245-249
        • Crump C.
        • Sundquist J.
        • Winkleby M.A.
        • Sundquist K.
        Interactive effects of physical fitness and body mass index on the risk of hypertension.
        JAMA Intern Med. 2016; 176: 210-216
        • Hogstrom G.
        • Nordstrom A.
        • Nordstrom P.
        High aerobic fitness in late adolescence is associated with a reduced risk of myocardial infarction later in life: a nationwide cohort study in men.
        Eur Heart J. 2014; 35: 3133-3140
        • Crump C.
        • Sundquist J.
        • Winkleby M.A.
        • Sundquist K.
        Interactive effects of physical fitness and body mass index on risk of stroke: a national cohort study.
        Int J Stroke. 2016; 11: 683-694
        • Shah R.V.
        • Murthy V.L.
        • Colangelo L.A.
        • et al.
        Association of fitness in young adulthood with survival and cardiovascular risk: the Coronary Artery Risk Development in Young Adults (CARDIA) study.
        JAMA Intern Med. 2016; 176: 87-95
        • Hogstrom G.
        • Nordstrom A.
        • Nordstrom P.
        Aerobic fitness in late adolescence and the risk of early death: a prospective cohort study of 1.3 million Swedish men.
        Int J Epidemiol. 2016; 45: 1159-1168
        • Kristensen P.L.
        • Wedderkopp N.
        • Moller N.C.
        • Andersen L.B.
        • Bai C.N.
        • Froberg K.
        Tracking and prevalence of cardiovascular disease risk factors across socio-economic classes: a longitudinal substudy of the European Youth Heart Study.
        BMC Public Health. 2006; 6: 20
        • Andersen L.B.
        • Haraldsdottir J.
        Tracking of cardiovascular disease risk factors including maximal oxygen uptake and physical activity from late teenage to adulthood: an 8-year follow-up study.
        J Intern Med. 1993; 234: 309-315
        • Dwyer T.
        • Magnussen C.G.
        • Schmidt M.D.
        • et al.
        Decline in physical fitness from childhood to adulthood associated with increased obesity and insulin resistance in adults.
        Diabetes Care. 2009; 32: 683-687
        • Camhi S.M.
        • Katzmarzyk P.T.
        Tracking of cardiometabolic risk factor clustering from childhood to adulthood.
        Int J Pediatr Obes. 2010; 5: 122-129
        • Ruiz J.R.
        • Ortega F.B.
        • Rizzo N.S.
        • et al.
        High cardiovascular fitness is associated with low metabolic risk score in children: the European Youth Heart Study.
        Pediatr Res. 2007; 61: 350-355
        • Mesa J.L.
        • Ruiz J.R.
        • Ortega F.B.
        • et al.
        Aerobic physical fitness in relation to blood lipids and fasting glycaemia in adolescents: influence of weight status.
        Nutr Metab Cardiovasc Dis. 2006; 16: 285-293
        • Adegboye A.R.
        • Anderssen S.A.
        • Froberg K.
        • et al.
        Recommended aerobic fitness level for metabolic health in children and adolescents: a study of diagnostic accuracy.
        Br J Sports Med. 2011; 45: 722-728
        • Boddy L.M.
        • Thomas N.E.
        • Fairclough S.J.
        • et al.
        ROC generated thresholds for field-assessed aerobic fitness related to body size and cardiometabolic risk in schoolchildren.
        PLoS One. 2012; 7: e45755
        • Moreira C.
        • Santos R.
        • Ruiz J.R.
        • et al.
        Comparison of different VO(2max) equations in the ability to discriminate the metabolic risk in Portuguese adolescents.
        J Sci Med Sport. 2011; 14: 79-84
        • Welk G.J.
        • Laurson K.R.
        • Eisenmann J.C.
        • Cureton K.J.
        Development of youth aerobic-capacity standards using receiver operating characteristic curves.
        Am J Prev Med. 2011; 41: S111-S116
        • Olds T.
        • Tomkinson G.
        • Leger 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: 1025-1038