European Journal of Cardiovascular Medicine

Obesity and overweight are health related problems which have taken epidemic proportions in the last decades. Obesity is closely related to the risk of developing cardiovascular diseases¹ and is currently considered as a serious health concern^1,2 Epidemiological studies have shown a rapid increase in the prevalence of overweight and obesity not only in adults, but also in children and adolescents thus increasing the risk of developing early CVD and co morbidities ^3,4

According  to the world health organization, approximately 20 % of children and adolescents in western countries are overweight or obese.⁵  From 1980 to 2013, prevalence in developing countries has increased in  children and adolescents from 8.1% to 12.9% for boys and from 8.4 % to 13.4% in girls ⁶.excess body weight in childhood and adolescence is associated with a higher risk of premature death and disability in adulthood and are also more likely to develop non communicable diseases such as diabetes at younger age.⁷

Obesity is an excess adipose tissue that results from a combination of genetic predisposition, environmental influences, and behavioral components.⁸ Most popular index to compare body composition of people and to categorize them as obese and non obese is the body mass index, a measurement which compares weight and height and defines people as overweight when their BMI more than 25kg/m2 and obese when it is greater than 30 kg/m2.¹

Physical fitness is defined as the ability to carry out daily tasks with vigor and alertness without undue fatigue and with ample energy to enjoy leisure time pursuits, to meet unusual situations and unforeseen emergencies.⁹ For a common man physical fitness is the ability to withstand stress and pressure under different circumstances where an unfit person would be ineffective or would quit. Physical fitness is modifiable through exercise training. The most frequently cited components fall into two groups: one related to health and the other related to skills. The health related components are cardio respiratory fitness, which reflects the capacity of the respiratory and cardiovascular system to bear prolonged exercise: Muscular strength is an essential component for daily life. Flexibility is the component that relates to the range of motion available at the joint. Each of these components varies with age and gender¹⁰

Many studies have reported that overweight and obesity decreased the physical exercise capability and then reduced cardio respiratory fitness and speed of movement.^11,12 Maintaining an appropriate level of health related physical fitness allows a person to reduce the risk of disease and injury. With the rapid increase in obesity and decrease in physical fitness among children, a relationship between overweight/ obesity and health related physical fitness is assumed.

Previously the only fitness criteria were weight and height tables: however they are not sufficient enough to reflex the true functional fitness status of the individual. In past decade different health related fitness components were identified. These are muscle strength, muscular endurance and body flexibility.

The current educational system in our country has helped to improve the educational standards, but the non active sedentary stressful life has made the youth physically unfit. Students of  MBBS course have a schedule consisting of lectures, practical and examinations, due to which making time available for exercise is difficult.

It is necessary to know the physical fitness level of MBBS students so that they can acquire the healthy lifestyle from the beginning so that they are motivated to be healthy throughout their life. Physically active medical students tend to recommend physical activity for patients or at risk individuals in their future practice.¹³The attitude of medical students towards the regular physical exercise is central in developing the prevention oriented behavior of new physicians. Hence we planned a study to assess physical fitness among normal, overweight and obese medical students and influence of gender on the physical fitness parameters such as muscle strength, muscular endurance and body flexibility.

A cross sectional observational study was planned at the Physiology department of a tertiary health care facility. The study was approved by the Institutional Ethics Committee. Study population was the first year MBBS students who were ranging between the age groups of 17-19 years. A total sample size of 180 medical students including both boys and girls was selected. The sample size was calculated with assumptions of correlation of physical; fitness parameter (flexibility) with BMI. After adding 10 % non response/dropout, final sample size in each group came out to be 90. Students with age less than 17 and more than 19 were excluded from the study. Exclusion criteria also included the students with medical history of any acute or chronic diseases or on medical treatment, students involved in regular sports activities and exercise, students not willing to participate in the study. The study participants were explained about the purpose of the study and written informed consent was taken from them. The participants were divided into three groups as normal, overweight and obese.  Pre structured case record form was used to obtain information on socio demographic factors, past medical history, anthropometric parameters and physical fitness parameters.

Height was measured in the standing position with bare foot against the wall with heels, buttocks and shoulders touching the wall and gaze horizontal. Stadiometer was used to measure the height to the nearest 0.5 cm. Weight was recorded with a portable digital weighing machine. The weight was recorded to the nearest 0.5 kg. Body mass index was calculated using a formula wt in kg/Ht in m2.waist circumference was measured at the midpoint between the lower margin of last palpable rib and the top of iliac crest using stretch resistant tape. The waist circumference was recorded to the nearest 0.05 cm. Hip circumference was measured around widest portion of buttock. The hip circumference was recorded to the nearest 0.5 cm.¹⁴

Muscle strength: It was evaluated by using a handgrip dynamometer. The participant was asked to hold the handgrip spring dynamometer in the right (dominant) hand to get a full grip of it. The participant compresses the handles of the dynamometer by putting in maximum effort for few seconds. No other body movement was allowed. The maximum isometric tension was directly recorded from the dial of the dynamometer. This procedure was repeated thrice with 2 min of rest in between, to prevent fatigue. The mean of the three readings was taken as the maximal isometric tension (T max). The values were taken in kilograms(Kg).¹⁵

Abdominal muscular endurance: It was assessed using the sit up test. The participant was asked to lie in supine position with the knees flexed at 90 degrees , the heels flat on the ground, and the arms crosses across their chest and the hands positioned on their opposite shoulders. The feet was held to the ground by the examiner. On the start command, participants raise their shoulders from the ground while keeping their arm crossed, and touched their elbows to their knees. They then descend back down until the shoulders blades touch the ground.  The participant does as many pushups as possible for 60 seconds using this technique. The total number of pushups performed in one minute was noted.¹⁶

Abdominal flexibility: The sit and reach test was performed following specific instructions. Lower body flexibility was assessed while attempting to reach forward as far as possible keeping knees straight in a sitting position. Sit and reach box was used to record the distance reached by the hand in cm.¹⁷

Statistical analysis

Data was expressed as mean ± SD. Comparison of data was done by using one way analysis of variance (ANOVA) followed by least significant difference (LSD) test. P value of less than 0.05 indicates a significant difference.

Table 1 does not show any statistical difference in the mean age of  group 1, 2 and 3. Table 2 shows the sex distribution among medical students. Table 3 shows anthropometric parameters among all groups. The mean weight, BMI and waist circumference values of group 1, 2 and 3 were statistically different from each other (p<0.05).The mean height, hip circumference and waist hip ratio did not show any statistically significant difference (p>0.05).

Table 4 shows the comparison of different physical fitness parameters between boys and girls. When the physical fitness parameters such as muscle strength, abdominal flexibility and abdominal muscle endurance in normal weight, overweight and obese boys were compared with the similar groups in girls, no statistically significant difference was  observed.(P>0.05)

Table 5 depicts the comparison of physical fitness parameters in all group; boys and all group; girls. There was progressively increase in mean values of muscle strength in boys in group 2 and 3 as compared to group 1 and the increase was statistically significant(p<0.05).There was progressive decline in the mean values of abdominal flexibility and abdominal muscle endurance in boys in group 2 and 3  than group 1 which was statistically significant. Comparison of physical fitness parameters in girls of various groups showed progressive increase in the mean values of muscle strength from group 1 to group 3 which was statistically significant with the p value of 0.05.There was statistically significant decline in the mean values of abdominal flexibility and abdominal muscle endurance in girls in group 2 and 3 when compared to group 1(p<0.05).

Table 6 shows comparison of physical fitness parameters among all groups. There was progressive increase in mean values of muscle strength in group 2 and 3 as compared to group 1 with statistically significant difference (p<0.05). there was progressive decline in the mean values of abdominal flexibility and abdominal muscle endurance in group 2 and 3 as compared to group 1 and the difference was statistically significant(P<0.05)

Table 1: Age distribution among groups

Table 2: Sex distribution among groups

Table 3: Anthropometric characteristics among all group medical students

P<0.05 statistically significant

Table 4: Comparison of physical fitness parameters in normal, overweight and obese boy’s vs. girls

P<0.05: statistically significant

Table 5 : Comparison of physical fitness parameters in all group boys and in all group girls

P<0.05: statistically significant

Table 6: Comparison of physical fitness parameters in all groups:

Obesity is rapidly escalating global hazard in all age groups. Physical activity plays an important role in obesity control because it alters the balance between caloric intake and expenditure. The relations of obesity to physical activity and physical fitness are less known. The present cross sectional observation study was undertaken to determine physical fitness parameters in normal weight, overweight and obese first year medical students

Anthropometric characteristics

The mean weight, BMI and waist circumference values of group 1,2 and 3 were statistically different from each other. The mean height, hip circumference and waist hip ratio were not statistically significant. similar findings were seen in JuozasRaistenskis et al ¹⁸study on physical activity and physical fitness in obese, overweight and normal weight children where no statistical difference was found in all groups. However BMI and waist hip ratio showed statistically significant difference in boys as compared to girls.

Bhojani et al studied physical fitness among adolescent girls in the age group of 16-19 years showed highly significant difference between the groups in BMI and waist hip ratio¹⁹

Comparison of physical fitness parameters in boys vs girls

A study by Paschaleri Z et al evaluated the physical activity and physical fitness levels in children with different body mass index observed boys obtained significant better performance than girls in both the BMI groups (normal vs overweight/obese). They also observed that sufficient levels daily physical activity lead to good physical performance and boys were more physically active than girls ²⁰The results of the study done by Gemma maria ¹⁷are consistent with our study but the age group was11-14 years school going children. A study by sai vaishnav Polina  in 18 -25 years old interns and found increased muscle strength and endurance in boys and more flexibility in girls ²¹

Comparison of physical fitness parameters in all group boys

Muscle strength measured by handgrip test was more in obese as compared to non obese.  Which is similar to the findings to the study done  by Susuki et al in 9-10 years old children and also in a study done by Deforche B et al ^22,23.

Comparison of physical fitness parameters in all group girls

Our study showed decreased muscular endurance and flexibility in overweight and obese girls as compared to their normal counterparts. Bhojani et al studied physical fitness among adolescent girls in the age group of 16-19 years observed that overweight and underweight girls showed poor muscular endurance and flexibility than normal weight girls.¹⁹

Comparison of physical fitness parameters in all groups:

Our study findings were similar to a study conducted by JuozasRaistenskis et al on physical fitness in normal weight, overweight and obese children where obese and overweight children had lower physical fitness than normal weight children¹⁸ Other investigators^24,25also reported inferior performances in obese participants on  fitness compared with their non obese counterparts.

Some investigators^19,23 observed no significant difference in the fitness test parameters in normal vs overweight/obsess groups which is in contrast to present study. This difference may be because of the study population which wer the school  going children in the age group of 11- 14 years.

Muscle strength measured by handgrip test was more in obese as compared to non obese which can be explained by their increased fat free mass. Obese individuals develop increased fat free mass as they accumulate excess adiposity.The excess fat free mass may be to support this extra load.^26,27

Abdominal endurance which was tested by sit ups was poor in obese than non obese which is probably due to the fact that their excess body fat was an extra load to be move during sit ups.²⁸Another explanation could be that obese and adolescent children avoid weight bearing activities because of the greater energy cost compared with normal weight children. ²⁹ In our study poorer performances could be also due to lack of experience in weight bearing tasks. Decreased flexibility in overweight and obese can be attributed to limit in the range of motion due to excess weight.

In overweight and obese groups muscle strength was more and abdominal muscle endurance and abdominal muscle flexibility was less as compared to their normal weight counterparts. Thus the study showed an increase in muscle strength with increase in body weight but decrease in flexibility and endurance as the weight increases in both the sexes. As we have found that abdominal flexibility and endurance decreases with increase in weight, students can be motivated to focus on the exercises which will increase their flexibility and endurance so that they can come out as strong and flexible future doctors who can make some difference in their patient’s lives.

Study limitation: Underweight medical students were not enrolled in the study. Other components of the Physical fitness such as cardiorespiratory fitness and body composition parameters were not included in the study. Also we have not taken into consideration of the physical activity levels of the students. More studies including all the components of the physical fitness and physical fitness level of the students can be done for the better results.

Acknowledgement: We acknowledge the first year medical students for their cooperation during the study.

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