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Association of Fitness With Life Satisfaction, Health Risk Behaviors, and Adherence to the Mediterranean Diet in Spanish Adolescents

Grao-Cruces, Alberto; Fernández-Martínez, Antonio; Nuviala, Alberto

Journal of Strength and Conditioning Research: August 2014 - Volume 28 - Issue 8 - p 2164–2172
doi: 10.1519/JSC.0000000000000363
Original Research
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Grao-Cruces, A, Fernández-Martínez, A, and Nuviala, A. Association of fitness with life satisfaction, health risk behaviors, and adherence to the Mediterranean diet in Spanish adolescents. J Strength Cond Res 28(8): 2164–2172, 2014—The aim of this study was to examine the association between aerobic, musculoskeletal, and motor capacity and life satisfaction, risk behavior, and adherence to the Mediterranean diet in adolescents. A total of 1,988 Spanish adolescents (12–16 years old) participated in this cross-sectional study. Life satisfaction, risk behavior, and adherence to the Mediterranean diet were measured by validated questionnaires for these ages. Aerobic, musculoskeletal muscle, and motor capacity were evaluated objectively with the ALPHA battery tests. Adolescents with low aerobic capacity had a higher risk of showing less (vs. very happy) life satisfaction (odds ratio [OR] = 1.303, 95% confidence interval [CI] = 1,054–1,611). These adolescents were also more likely to report risk behaviors such as sometimes (vs. never) of smoking tobacco (OR = 1.752, 95% CI = 1,218–2,520), besides having a low adherence to the Mediterranean diet (vs. high) (OR = 1.410, 95% CI = 1,113–1,786). Adolescents with low upper-body musculoskeletal capacity showed a lower risk of reporting risk behaviors such as alcohol consumption or getting drunk occasionally (vs. never) (OR = 0.662, 95% CI = 520–843; OR = 0.561, 95% CI = 419–753, respectively). The results suggest that the aerobic capacity contributes significantly to greater adherence to the Mediterranean diet, greater life satisfaction, and lower tobacco consumption, whereas musculoskeletal capacity seems to be related to alcohol consumption.

Research group SEJ 046 Laboratory, Department of Sport and Computer Science, Pablo de Olavide University, Seville, Spain

Address correspondence to Alberto Grao-Cruces, agracru@upo.es.

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Introduction

Physical fitness (PF) is recognized as a powerful health marker during childhood and adolescence. Its development is now an essential resource for maintaining vital functions because several studies have established PF as a predictor of morbidity and mortality throughout life (26,33,35). It has been verified that children and adolescents with low PF levels have a higher risk of cardiovascular, metabolic, or skeletal diseases (13,26,33). However, nowadays, there are very few studies that relate PF to life satisfaction, the consumption of damaging substances, and healthy eating habits, even finding contradictory results.

Life satisfaction is an overall assessment that the person makes about his/her own life (30). Longitudinal and cross-sectional studies have demonstrated the importance of life satisfaction for adolescents' proper growth and development, helping in social relationships, and preventing psychological disorders and unhealthy behaviors (43). Previous studies suggest a positive association between physical activity (17), aerobic (27), and musculoskeletal capacity (28) with life satisfaction in children and adolescents, but the results are inconclusive.

Other determining factors that increase health problems in Western countries are related to tobacco and alcohol consumption. These risk behaviors are associated with the leading causes of morbidity and mortality, and their effects are even more harmful in children and adolescents, whose organisms are more sensitive to these substances (12,32). It seems that both unhealthy habits (tobacco and alcohol) are correlated with the level of aerobic and musculoskeletal capacity (8,28), but the relationship was not significant in all cases because Castro-Piñero et al. (8) concluded that low levels of aerobic capacity increase the risk for alcohol but not tobacco. A negative relationship between the practice of PA and tobacco consumption in adolescents has been established by a considerable number of studies (9,17). However, others have shown that this relationship is not always significant (29,31) or that said association occurs only in boys but not in girls in Spanish teenagers (23). Regarding the relationship between PA and alcohol consumption, the results from previous studies are even more contradictory. Some found no significant association between these variables (10), and the authors who did find it do not agree on whether the relationship is positive or negative (18,29).

However, among the factors, which contribute to the prevention of premature health problems are those related to the maintenance of healthy eating patterns such as the typical Mediterranean diet. This diet is characterized by being rich in natural antioxidants, poor in saturated fat, and based on the consumption of fruits, vegetables, legumes, fish, nuts, and olive oil (4). This model of diet plays a preventive role in the development of cardiovascular and cerebrovascular diseases, diabetes, obesity, oncological, and neurodegenerative diseases (5,23). Previous works have shown a positive relationship between physical activity and the degree of adherence to the Mediterranean diet in children and adolescents (11,14,37). However, these studies are still scarce, and we are not aware of any research that has studied the link between PF and adherence to the Mediterranean diet at this age. In addition, the progressive neglect of healthy eating patterns in adolescents from Mediterranean countries could be related to the onset of premature health problems (42).

This is why this study is aimed at analyzing the association of aerobic, musculoskeletal, and motor capacity with life satisfaction, risk behavior, and adherence to the Mediterranean diet in adolescents. The main hypotheses tested in this study are teenagers those with a low aerobic capacity, low musculoskeletal fitness, and low motor capacity (compared with those with high PF), will show a higher risk of presenting lower life satisfaction, risk behaviors, and having a low adherence to the Mediterranean diet.

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Methods

Experimental Approach to the Problem

It is well known that PF is a powerful health marker during adolescence (26,33,35). However, PF relationship with subjective well-being indicators, consumption of substance abuse, and healthy eating habits is less evident, and the results to date are scarce or contradictory. To clarify whether having higher levels of PF could have a positive effect on life satisfaction, health risk behaviors, and adherence to the Mediterranean diet in youth. A cross-sectional study was conducted examining the association of cardiorespiratory fitness, muscular fitness, and motor fitness with life satisfaction, substance abuse, and adherence to the Mediterranean diet in 12- to 16-year-old teenagers.

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Subjects

A total of 1,988 (1,005 boys and 983 girls) healthy Caucasian teenagers (mean age ± SD, 13.89 ± 1.29 years, 12–16 years, 7th–10th grade, mean body mass index [BMI] ± SD, 22.23 ± 4.45 kg·m−2) participated in this study. Data collection took place from September to November 2011. Teenagers from 16 educational centers of the 8 provinces of Andalusia (south of Spain) were surveyed. They were randomly selected by 2-stage cluster sampling using the database of the census of the Autonomous Region of Andalusia as a reference. The different strata were selected, according to the geographical localization, by age and sex. The participation rate allowed working with a margin of error of less than 2.5% and a 95% confidence level.

Teenagers, parents, teachers, and principals of the participating centers were informed on the nature and objectives of this study at a meeting, in which informed consent from parents and teenagers was required. The work met the highest standards of safety and ethics, the laws of the country, where they were performed, and the ethical standards established for this type of study at the authors' University, whose Institutional Review Board for human use approved the study. It was developed after the ethical guidelines of the Declaration of Helsinki in 2008.

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Procedures

Weight (scale TANITA BC-420-S—Class III [TANITA Corporation Inc., Arlington Heights, Illinois, USA]) and height (SECA 214 portable stadiometer [Seca Ltd., Hamburg, Germany]) anthropometric measurements were performed with the adolescents barefooted and wearing light clothes. The aerobic, musculoskeletal, and motor capacity was measured objectively with a 48-hour period between each one. Adolescents completed an anonymous questionnaire for adolescents (average completion time, 12 minutes) to assess life satisfaction, risk behavior, and adherence to the Mediterranean diet. All measurements were performed in the presence of trained researchers, who were always the same. All participants were instructed to understand the PF trials by previously practicing them. Thereafter, if tests were not conducted properly, these were not included in the study and were not repeated. They were also instructed to refrain from strenuous exercise within the 48 hours before these tests. These measurements were taken in 4 sessions with a 48-hour period between each one. The tests were always performed in the same order: anthropometric measurements and aerobic capacity in the first session, muscular fitness in the second and third sessions (one for each test), and motor fitness test and questionnaire in the last session.

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Cardiorespiratory Fitness

Aerobic capacity was estimated using the 20-m shuttle run test described by Léger et al. (20) and included in the PF battery ALPHA (34). Participants were asked to run between 2 lines 20 m apart while keeping a pace with the acoustic signals from a compact disc previously recorded. The initial speed was 8.50 km·h−1, which was increased to 50 km·h−1 per minute (1 minute = 1 stage). Participants were instructed to run in a straight line to pivot on completing the itinerary between the 2 lines and to follow the pace set by the audio signals. Subjects were encouraged to continue running if they were able to, during the course of the test. The test ended when the participant failed to reach the end of the lines concurrent with the audio signals on 2 consecutive occasions. Otherwise, the test ended when the subject stopped because of fatigue. All measurements were performed under standardized conditions on a runway covered with a rubber floor. We scored the last completed stage (precision 50 stages). These stages were transformed to relative values of maximum oxygen consumption using the formulas of Léger et al. (20). Participants were classified into low and high aerobic capacity according to the FITNESSGRAM normative values for the physical health area (41).

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Muscular Fitness

In accordance with the recommendations of Ruiz et al. (34), the 2 tests were used for validity and reliability in adolescents; PF ALPHA battery gathered musculoskeletal capacity measurements. Musculoskeletal capacity of the lower limbs was evaluated by the standing long jump test. The participants, who are behind the take-off line with feet together, propel themselves to jump forward as far as possible. The distance was measured from the take-off line to the back of the heel that landed closest to the take-off line. The test was performed twice, and the best result was taken as valid (in centimeter) (2,28).

The upper-limb musculoskeletal capacity was assessed by handgrip strength test using the dynamometer TKK5101 Grip D—Class III (Takey, Tokyo, Japan) to the nearest 0.1 kg. Participants pressed gradually and continuously for at least 2 seconds, standing for the entire test, with the arm straight out without touching any part of the body with the dynamometer, except the hand that is being measured. The test was performed twice with each hand, alternately and randomly selecting the starting hand. The sum of the best result in each hand (in kilograms) (2) was used. For each test, subjects were classified into the categories of low and high level of musculoskeletal capacity, according to a measurement of central tendency (28), in this case, the mean.

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Motor Fitness

According to Ruiz et al. (34) to measure motor skills, the 4 × 10 m shuttle run test is used. This test is automatically measured by photoelectric cells (Microgate, Bolzano, Italy). Participants ran 4 times, at the maximum possible speed, between 2 lines 10 m apart. At the end of each section, the subjects took (the first time) or changed (all other times) a sponge on the line marked on the floor, crossing this line with both feet. Participants were instructed to run in a straight line. The test was performed twice, and the best result was kept (in seconds with a decimal) (1). Subjects were classified into the categories of low and high motor capacity, according to the mean.

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Life Satisfaction

To assess the Spanish version of life satisfaction, validated in adolescents, the Satisfaction with Life Scale (3) was used. This scale has 5 items whose response values range from 1 to 5, where 1 indicates “strongly disagree” and 5 “strongly agree.” The final result of the scale was calculated by adding the scores obtained in each of its items (5–25). The end result was dichotomized as very happy (21–25) or unhappy (5–20). The internal consistency of the scale in the study sample was high (Cronbach's alpha = 0.824).

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Risk Behaviors

The risk behaviors were measured by means of Health Behavior in a School-Aged Children questionnaire (21).

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Tobacco Consumption

A single item was used, asking “How often do you smoke tobacco at the moment?” The response scale presented 4 options: 1 = I do not smoke, 2 = less than once a week, 3 = at least once a week, but not daily, and 4 = every day. Responses were dichotomized as never (1) and sometimes (2–4).

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Alcohol Consumption

Participants indicated how often they drank each of the following 3 beverages: beer, wine, and spirits. The response scale presented 5 options, converted to days per week: 0 = never, 0.10 = rarely, 0.25 = every month, 1 = every week, 7 = every day. An average of the 3 responses accounted for alcohol consumption (16). Responses were dichotomized as never (0) and sometimes (>0). The internal consistency of the scale in the study sample was high (Cronbach's alpha = 0.788).

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Drunkenness

A single item was used to assess how often they had been drunk, “Have you ever drunk so much alcohol that you got really drunk?” The response scale presented 5 options: 0 = never, 1 = once, 2 = 2–3 times, 3 = 4–10 times, and 4 = more than 10 times. Responses were dichotomized as never (0) or sometimes (1–4).

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Adherence to the Mediterranean Diet

Adherence to the Mediterranean dietary pattern was evaluated by using the adhesion test to the Mediterranean Diet KIDMED, which has been used successfully in Spanish adolescents (14,37). This instrument consists of 16 dichotomy questions that should be answered affirmatively/negatively (yes/no). Affirmative answers to the questions that represent a positive aspect relating to the Mediterranean diet (12 questions) add 1 point, whereas affirmative answers to questions representing a negative connotation about the Mediterranean diet (4 questions) subtract 1 point. Negative answers do not score. The total score results in KIDMED index, in which participants are classified into the categories of high (8–12) and low adherence (0–7) to the Mediterranean diet.

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Statistical Analyses

IBM SPSS Statistics 20.0 for Windows (IBM Software Group, Chicago, IL, USA) was used to perform the analysis, and the significance level was established at 0.05. Comparisons between sexes of the anthropometric measurements, PF tests, life satisfaction, risk behavior, and adherence to the Mediterranean diet were performed using Student's t-test for independent samples.

The association of aerobic, musculoskeletal, and motor capacity with life satisfaction, risk behavior, and adherence to the Mediterranean diet was examined by regression analysis. In addition, binary logistic regression analysis was carried out to examine the association between low aerobic capacity (41), low musculoskeletal capacity (below average), and low motor capacity (below average) with life satisfaction (very happy [referent] vs. not very happy), risk behavior (tobacco and alcohol consumption and drunkenness: never [referent] vs. sometimes), and adherence to the Mediterranean diet (high [referent] vs. medium-low). All these analyses were performed jointly for boys and girls, and all models were adjusted for sex, age, and BMI.

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Results

The boys showed significantly higher BMI, aerobic, musculoskeletal and motor capacity life satisfaction, and adherence to the Mediterranean diet than girls, whereas the girls showed higher tobacco consumption (Table 1). Table 2 shows the association of aerobic, musculoskeletal, and motor capacity with life satisfaction, risk behavior, and adherence to the Mediterranean diet. Aerobic capacity was positively associated with life satisfaction and the degree of adherence to the Mediterranean diet (β = 0.094 and 0.069, respectively) and negatively with the tobacco consumption (β = −0.075). The lower-body musculoskeletal capacity was positively associated with life satisfaction and episodes of drunkenness (β = 0.092 and 0.067, respectively), whereas the upper-body musculoskeletal capacity was positively associated with alcohol consumption and drunkenness (β = 0.146 and 0.192, respectively). Motor fitness was positively associated with life satisfaction (β = 0.091).

Table 1

Table 1

Table 2

Table 2

Adolescents with low aerobic capacity had significantly higher odds ratios (OR) on considering their life satisfaction as low, being smokers and having a diet far from Mediterranean dietary patterns (OR = 1.303, 1.752, and 1.410, respectively). Participants with low musculoskeletal capacity in the upper body showed significantly less OR in alcohol consumption while having reached the state of intoxication at least once (OR = 0.662 and 0.561, respectively). No significant association was observed for low musculoskeletal capacity in the lower body and motor capacity (Table 3).

Table 3-a

Table 3-a

Table 3-b

Table 3-b

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Discussion

This study sought to analyze PF association with life satisfaction, risk behaviors, and adherence to the Mediterranean diet in adolescents. The results show that aerobic capacity is positively associated with life satisfaction and adherence to the Mediterranean diet in adolescents. We also highlight the association of aerobic capacity with a risk behavior such as tobacco consumption, in such a way that adolescents with higher aerobic capacity reported lower tobacco consumption. In contrast, the upper-body musculoskeletal capacity showed a positive association with alcohol risk behaviors and intoxication episodes. These results demonstrate the importance of developing aerobic capacity to reduce the risk of premature health problems.

Aerobic capacity was positively associated to life satisfaction in adolescents after the findings of Padilla-Moledo et al. (27) in a sample of 684 Spanish schoolchildren between 6 and 17.90 years. Life satisfaction is a key indicator of welfare and particularly important for the proper development of adolescents (39). At the same time, aerobic capacity has proved an important marker of cardiovascular and metabolic health (13). We are not aware of the existence of more research that studies the link between aerobic capacity and life satisfaction in adolescents, thus making more comparisons difficult. However, other studies have found that physical activity and sport participation are positively associated to life satisfaction at these ages (17,29), thus agreeing with our results.

This study has revealed that aerobic capacity is inversely associated with tobacco consumption in adolescents, in agreement with previous studies. Bernaards et al. (5) observed this inverse association in a longitudinal study with 632 Dutch youths. Montoye et al. (22) in a sample of 597 (16-to 69-year-old) males found that this association was more consistent among younger subjects. The results of Castro-Piñero et al. (8) in 691 Spanish children and adolescents were also along this line, although no statistical significance in the association was found. The works that have studied the association between physical activity and tobacco consumption also largely coincide with our findings (9,16,17), although in some of them, the association is not significant nor is only in males (23,29). Given the transversal nature of the study, we cannot assure the direction of this association, it is possible that the aerobic capacity and tobacco consumption influence each other mutually. In fact, aerobic capacity depends largely on the ability of the cardiovascular and pulmonary systems to deliver adequate oxygen to muscle tissues (13), and the harmful effects of tobacco to the lung function are well known (32). Whereas, other PF components do not largely depend on the pulmonary system.

However, alcohol consumption was not associated with aerobic capacity. This confirms the findings of Montoye et al. (22), who in their group of subjects of 16–20 years old found lower aerobic capacity development among young nondrinkers and those who drank more, whereas those who drank only moderately showed the highest levels of aerobic capacity. Castro-Piñero et al. (8) in 691 Spanish schoolchildren of 6–17.90 years old also found no association between aerobic capacity and tobacco consumption; yet in contrast to our results, they did observe a greater likelihood of alcohol consumption and getting drunk occasionally among subjects with a lower aerobic capacity. Currently, there is no consensus on the effects that physical activity can have on alcohol consumption in this age group (10,29,40).

Both aerobic capacity and adherence to Mediterranean dietary patterns have been shown to prevent the onset of cardiovascular and metabolic diseases (6,13,24). We are not aware of any previous research that has studied the association between both variables, which makes the discussion difficult. Yet several studies have shown the positive association of physical activity with adherence to the Mediterranean diet, such as Schröder et al. (37) in a sample of 2,513 young Spanish people aged 10–24 years old, Grao-Cruces et al. (14) in 1,973 Spanish adolescents aged 11–18 years old, and Farajian et al. (11) in a sample of 4,786 Greek children aged 10–12 years old. These results are in line with Groth and Morrison-Beedy (15), who affirm that healthy behaviors tend to occur in groups, which argues by extending the theory of planned behavior beyond individual behaviors to related behaviors groups.

The results showed a positive association between musculoskeletal capacity and life satisfaction in adolescents, agreeing with the results of Padilla-Moledo et al. (28) in 690 Spanish children and adolescents of 6–17.90 years old. Although this association was only significant for lower-body musculoskeletal capacity in this study, it was not for the one developed for the upper limbs. We also disagree with quoted work in which we did not observe any significant increased risk of dissatisfaction with life among subjects with low musculoskeletal capacity, regardless of the assessment tests used. The latter could be because of a very low musculoskeletal capacity mean value of the sample (19). Although few studies have researched the link between musculoskeletal ability and life satisfaction, other precedents do exist that associate life satisfaction with aerobic capacity and physical activity in adolescents, as previously discussed. Although it is true, the influence of aerobic capacity on some health indicators is more evident than that musculoskeletal capacity may have (13,26,34).

Positive association between musculoskeletal capacity and drunkenness, as well as an increased risk of consuming alcohol and getting drunk occasionally among adolescents with higher performances for the handgrip strength test was found, but not so for the standing long jump test. Results contrast with those obtained by Padilla-Moledo et al. (28) that in a sample of 690 Spanish scholars of 6–17.90 years old found inverse association between musculoskeletal capacity and tobacco consumption, alcohol, and drunkenness. However, our results are more in line with those that suggest that more physical exercise does not protect against alcohol consumption, which may even be higher among the most active subjects (7,25,29,31). We did not find any empirical evidence to justify why adolescents with higher musculoskeletal capacity in the upper body may be at an increased risk for alcohol and drunkenness. However, we can hypothesize about this. This finding may be because of the kind of PA performed by teenagers with higher handgrip strength. As argued by Ruiz-Risueño et al. (36), practicing collective sports can lead to a higher prevalence of alcohol consumption because after participation in team-sports meetings, the players usually go to leisure zones where they drink in greater quantities (38). This could also influence that smoking is related to some indicators of fitness but not to others.

No significant association was found between musculoskeletal capacity and adherence to the Mediterranean diet in adolescents. Considering the limited number of studies that have previously examined this association, it is difficult to compare our results. However, as we have discussed previously, adherence to the Mediterranean diet does seem to be more associated with physical activity levels and aerobic capacity at these ages. Nevertheless, the results obtained cannot compare the influence of musculoskeletal capacity on health indicators and lifestyle habits with those shown by aerobic capacity (13,26,34).

Motor ability, of the variables considered, was shown only to be significantly associated with life satisfaction in adolescents. But adolescents with higher motor capacity did not show significantly less risk of life dissatisfaction than their peers with poorer capacity. The latter could be because of a very low mean value in the subjects' motor capacity (19). Motor fitness (speed/agility) seems to be more related to adolescent bone health (26), and its evaluation is not so much of a priority for health as knowing aerobic and musculoskeletal capacity (34). In fact, its influence on adolescent health is not as obvious as the other components of PF (13,34).

We found that the descriptive and transversal nature among the limitations of the study, as no variable was manipulated experimentally, led to a causal relationship not being established. Another limitation was that life satisfaction, risk behavior, and adherence to the Mediterranean diet were measured by a self-administered questionnaire, so that some of its questions may have been misinterpreted deliberately or unintentionally by some teenagers. However, intentional misinformation was probably minimized by the fact that the questionnaires were completed anonymously, and all questionnaires showed good reliability and validity in this age group (12–16 years). In addition, the remaining variables were evaluated with objective measures.

The study revealed that aerobic capacity contributes significantly to greater adherence to the Mediterranean diet, greater life satisfaction, and lower tobacco consumption in adolescents. However, adolescents with higher musculoskeletal capacity in the upper body may be at increased risk for alcohol and drunkenness. These findings point to the need of increasing aerobic capacity during adolescence to positively influence life satisfaction and nutritional quality, as well as avoiding tobacco consumption. Similarly, they alert us to risk behaviors related to alcohol intake that may be observed in adolescents who have more musculoskeletal capacity.

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Practical Applications

The study highlights the importance of developing aerobic capacity at these ages. This capacity can be improved after recommendations such as the guidelines of Armstrong et al. (1), which recommend exercising in a range of intensity of 85–90% of maximal heart rate, with a frequency of 3 or 4 days per week, and during 30–40 minutes per session. Professionals should prioritize the work of aerobic capacity in the conditioning practice to improve life satisfaction and adherence to the Mediterranean diet and decrease tobacco consumption in adolescents.

Based on the results, not all kinds of PA appear effective for reducing the risk of substance abuse. Professionals in the conditioning field should be aware of this. They should be alert to prevent risk behaviors related to alcohol consumption in adolescents, especially in the sports disciplines that develop more handgrip strength. Further intervention studies are needed to confirm or refute these findings.

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Acknowledgments

This study was funded by Research Group SEJ 046 Physical Activity Analysis (Pablo de Olavide University, Spain). It also received support from the University Teaching Staff programme implemented by the Spanish Government, the Ministry of Education (AP-2009–3829).

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Keywords:

cardiorespiratory fitness; muscular fitness; well-being; tobacco; alcohol; nutrition

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