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Huffman KF, Ambrose KR, Nelson AE, Allen KD, Golightly YM, Callahan LF. The Critical Role of Physical Activity and Weight Management in Knee and Hip Osteoarthritis: A Narrative Review. J Rheumatol 2024; 51:224-233. [PMID: 38101914 PMCID: PMC10922233 DOI: 10.3899/jrheum.2023-0819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/17/2023]
Abstract
Physical activity (PA) and weight management are critical components of an effective knee and hip osteoarthritis (OA) management plan, yet most people with OA remain insufficiently active and/or overweight. Clinicians and their care teams play an important role in educating patients with OA about PA and weight management, eliciting patient motivation to engage in these strategies, and referring patients to appropriate self-management interventions. The purpose of this review is to educate clinicians about the current public health and clinical OA guidelines for PA and weight management and highlight a variety of evidence-based self-management interventions available in community and clinical settings and online.
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Affiliation(s)
- Katie F Huffman
- K.F. Huffman, MA, K.R. Ambrose, MS, Osteoarthritis Action Alliance, Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;
| | - Kirsten R Ambrose
- K.F. Huffman, MA, K.R. Ambrose, MS, Osteoarthritis Action Alliance, Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Amanda E Nelson
- A.E. Nelson, MD, Osteoarthritis Action Alliance, Thurston Arthritis Research Center, and Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kelli D Allen
- K.D. Allen, PhD, Osteoarthritis Action Alliance, Thurston Arthritis Research Center, and Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, and Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina
| | - Yvonne M Golightly
- Y.M. Golightly, PhD, Osteoarthritis Action Alliance, Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, and College of Allied Health Professions, University of Nebraska Medical Center, Omaha, Nebraska
| | - Leigh F Callahan
- L.F. Callahan, PhD, Osteoarthritis Action Alliance, Thurston Arthritis Research Center, and Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Department of Orthopaedics, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Marriott KA, Birmingham TB. Fundamentals of osteoarthritis. Rehabilitation: Exercise, diet, biomechanics, and physical therapist-delivered interventions. Osteoarthritis Cartilage 2023; 31:1312-1326. [PMID: 37423596 DOI: 10.1016/j.joca.2023.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023]
Abstract
Insights related to the pathogenesis of osteoarthritis (OA) have informed rehabilitative treatments that aim to mitigate the influence of several known impairments and risk factors for OA, with the goal to improve pain, function, and quality of life. The purpose of this invited narrative review is to provide fundamental knowledge to non-specialists about exercise and education, diet, biomechanical interventions, and other physical therapist-delivered treatments. In addition to summarizing the rationale for common rehabilitative therapies, we provide a synthesis of current core recommendations. Robust evidence based on randomized clinical trials supports exercise with education and diet as core treatments for OA. Structured, supervised exercise therapy is advised. The mode of exercise may vary but should be individualized. The dose should be based on an initial assessment, the desired physiological changes, and progressed when appropriate. Diet combined with exercise is strongly recommended and studies demonstrate a dose-response relationship between the magnitude of weight loss and symptom improvement. Recent evidence suggests the use of technology to remotely deliver exercise, diet and education interventions is cost-effective. Although several studies support the mechanisms for biomechanical interventions (e.g., bracing, shoe inserts) and physical therapist-delivered (passive) treatments (e.g., manual therapy, electrotherapeutic modalities) fewer rigorous randomized trials support their clinical use; these therapies are sometimes recommended as adjuncts to core treatments. The mechanisms of action for all rehabilitative interventions include contextual factors such as attention and placebo effects. These effects can challenge our interpretation of treatment efficacy from clinical trials, yet also provide opportunities to maximize patient outcomes in clinical practice. When evaluating rehabilitative interventions, the field may benefit from increased emphasis on research that considers contextual factors while evaluating mechanistic, longer-term, clinically-important and policy-relevant outcome measures.
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Affiliation(s)
- Kendal A Marriott
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.
| | - Trevor B Birmingham
- School of Physical Therapy, Faculty of Health Sciences, Bone and Joint Institute, University of Western Ontario, London, Ontario, Canada.
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Guan R, Li H, Jiao Y, Yu H. A nonrandomized controlled trial of individualized exercise prescription combined with remote exercise management in patients who are overweight or obese. BMC Sports Sci Med Rehabil 2022; 14:99. [PMID: 35655279 PMCID: PMC9161188 DOI: 10.1186/s13102-022-00479-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 04/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Between 2012 and 2020, the obesity rate increased among Chinese people aged 18 years and above, along with blood pressure, fasting blood glucose, serum total cholesterol, and triglycerides. Purpose Our objective was to compare the effects of a combined intervention, including individualized exercise prescription plus remote management versus individualized exercise prescription only, on cardiovascular risk factors in patients who are overweight or obese, with the aim of establishing a more effective remote model of health management than self-management. Methods This nonrandomized controlled trial (ChiCTR2100046307) studied patients who are overweight or obese at model labor health management centers from January 2019 to December 2019, including 55 people in the experimental group and 34 in the control group. The relevant indexes of all the research objects from both experimental group and control group were examined. Participants in the experimental group were given individualized exercise prescription combined with remote exercise management over a period of 3 months. The control group was prescribed exercise only at time of enrollment and taught about exercise once, followed by voluntary exercise and self-management for 3 months. Result After adjusting for baseline differences, the changes in weight (−2.72 ± 4.03 kg versus 0.32 ± 2.50 kg, P < 0.0001), body mass index (−0.99 ± 1.44 kg/m2 versus 0.11 ± 0.92 kg/m2, P < 0.0001), waist circumference (−2.98 ± 6.29 cm versus 0.60 ± 5.33 cm, P < 0.0001), visceral fat area (−9.75 ± 19.68 cm2 versus −1.31 ± 12.37 cm2, P = 0.028), body fat (− 2.65 ± 3.52 kg versus 0.54 ± 2.67 kg, P < 0.0001), body fat rate (−2.50 ± 3.32% versus 0.21 ± 3.30%, P < 0.0001), uric acid (−9.75 ± 19.68 µmol/L versus −1.31 ± 12.37 µmol/L, P = 0.028), serum total cholesterol (−0.11 ± 0.40 mmol/L versus −0.11 ± 0.59 mmol/L, P = 0.004), fasting insulin (− 2.36 ± 5.20 μU/mL versus 1.22 ± 7.34 μU/mL, P = 0.009), and homeostatic model assessment of insulin resistance (−0.62 ± 1.25 versus 0.14 ± 1.83, P = 0.022) were significantly better in the experimental group than in the control group after intervention. Conclusion Individualized exercise prescription combined with remote management in patients who are obese or overweight facilitated weight and fat loss, lowered blood pressure and serum total cholesterol, improved glucose metabolism and insulin resistance, and reduced cardiovascular risk factors. The intervention was superior to conventional education in terms of weight loss, fat reduction, total cholesterol reduction, fasting insulin reduction, and amelioration of insulin resistance.
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Affiliation(s)
- Rui Guan
- Department of Health Management, Beijing Rehabilitation Hospital, Capital Medical University, Xixiazhuang, Badachu, Shijingshan District, Beijing, 100144, China
| | - Haijing Li
- Department of Health Management, Beijing Rehabilitation Hospital, Capital Medical University, Xixiazhuang, Badachu, Shijingshan District, Beijing, 100144, China
| | - Yang Jiao
- Department of Health Management, Beijing Rehabilitation Hospital, Capital Medical University, Xixiazhuang, Badachu, Shijingshan District, Beijing, 100144, China.
| | - Hong Yu
- Department of Health Management, Beijing Rehabilitation Hospital, Capital Medical University, Xixiazhuang, Badachu, Shijingshan District, Beijing, 100144, China.
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Semeraro MD, Almer G, Renner W, Gruber HJ, Herrmann M. Influences of Long-Term Exercise and High-Fat Diet on Age-Related Telomere Shortening in Rats. Cells 2022; 11:1605. [PMID: 35626642 PMCID: PMC9139508 DOI: 10.3390/cells11101605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/22/2022] Open
Abstract
(1) Obesity and exercise are believed to modify age-related telomere shortening by regulating telomerase and shelterins. Existing studies are inconsistent and limited to peripheral blood mononuclear cells (PBMCs) and selected solid tissues. (2) Female Sprague Dawley (SD) rats received either standard diet (ND) or high-fat diet (HFD). For 10 months, half of the animals from both diet groups performed 30 min running at 30 cm/s on five consecutive days followed by two days of rest (exeND, exeHFD). The remaining animals served as sedentary controls (coND, coHFD). Relative telomere length (RTL) and mRNA expression of telomerase (TERT) and the shelterins TERF-1 and TERF-2 were mapped in PBMCs and nine solid tissues. (3) At study end, coND and coHFD animals showed comparable RTL in most tissues with no systematic differences in TERT, TERF-1 and TERF-2 expression. Only visceral fat of coHFD animals showed reduced RTL and lower expression of TERT, TERF-1 and TERF-2. Exercise had heterogeneous effects on RTL in exeND and exeHFD animals with longer telomeres in aorta and large intestine, but shorter telomeres in PBMCs and liver. Telomere-regulating genes showed inconsistent expression patterns. (4) In conclusion, regular exercise or HFD cannot systematically modify RTL by regulating the expression of telomerase and shelterins.
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Affiliation(s)
| | | | | | - Hans-Jürgen Gruber
- Clinical Institute of Medical and Chemical Laboratory Diagnostics (CIMCL), Medical University of Graz, 8036 Graz, Austria; (M.D.S.); (G.A.); (W.R.); (M.H.)
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Du Y, Xu T, Yin Z, Espinoza S, Xie Y, Gentry C, Tian Q, Zhao LJ, Shen H, Luo Z, Deng HW. Associations of physical activity with sarcopenia and sarcopenic obesity in middle-aged and older adults: the Louisiana osteoporosis study. BMC Public Health 2022; 22:896. [PMID: 35513868 PMCID: PMC9074188 DOI: 10.1186/s12889-022-13288-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/19/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This study examined the associations between physical activity, obesity, and sarcopenia in middle-aged and older adults. METHODS We analyzed the data of 8, 919 study participants aged between 45 to 97 (mean age = 57.2 ± 8.8) from a Southern state in the United States. Self-reported physical activity was classified to regular exercise ≥ 3 times/week, < 3 times/week, and no regular exercise. Associations between physical activity, obesity and sarcopenia were explored with generalized linear models and ordinal logistic regressions stratified by age (middle-aged and older adults) and gender adjusting for covariates. RESULTS In middle-aged and older adults, all examined obesity related traits (e.g., body mass index, waist circumference) were inversely associated with physical activity levels (p < 0.01) in both genders. Exercising ≥ 3 times/week was negatively associated with lean mass indicators (e.g., appendicular lean mass) in middle-aged and older females (p < 0.01), while the negative associations become positive after adjusting for weight. Positive associations between physical activity and grip strength were only found in middle-aged males (p < 0.05). Ordinal logistic regression revealed that those exercising ≥ 3 times/week were less likely to have obesity, sarcopenia, and sarcopenia obesity in all groups (p < 0.01), except for sarcopenia in older males and females (p > 0.05). Positive associations of exercising < 3 times/week with sarcopenia and sarcopenia obesity were only found in middled adults. CONCLUSION The associations of exercise frequency with obesity and sarcopenia vary considerably across gender and age groups. Exercise programs need to be individualized to optimize health benefits. Future research exploring physical activity strategies to balance weight reduction and lean mass maintaining is warranted in middle-aged and especially older adults.
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Affiliation(s)
- Yan Du
- School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Tao Xu
- College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Zenong Yin
- Department of Public Health, University of Texas at San Antonio, San Antonio, Texas, USA
| | - Sara Espinoza
- San Antonio Geriatric Research, Education, and Clinical Center, San Antonio, Texas, USA
- Division of Geriatrics, Gerontology & Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Sam and Ann Barshop Institute for Longevity and Aging Studies, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Yiqiong Xie
- Real World Research, Ontada, The Woodlands, Houston, USA
| | - Caleb Gentry
- Brown School at Washington University in St. Louis, St. Louis, USA
| | - Qing Tian
- Center for Bioinformatics and Genomics, School of Medicine, Tulane University; New Orleans, LA, New Orleans, United States of America
| | - Lan-Juan Zhao
- Center for Bioinformatics and Genomics, School of Medicine, Tulane University; New Orleans, LA, New Orleans, United States of America
| | - Hui Shen
- Center for Bioinformatics and Genomics, School of Medicine, Tulane University; New Orleans, LA, New Orleans, United States of America
| | - Zhe Luo
- Center for Bioinformatics and Genomics, School of Medicine, Tulane University; New Orleans, LA, New Orleans, United States of America
| | - Hong-Wen Deng
- Center for Bioinformatics and Genomics, School of Medicine, Tulane University; New Orleans, LA, New Orleans, United States of America.
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Effect of Neuromuscular Electrical Stimulation During Walking on Pain Sensitivity in Women With Obesity With Knee Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil 2022; 103:1707-1714. [PMID: 35337843 DOI: 10.1016/j.apmr.2022.01.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the extent to which pain sensitivity is altered in women with obesity with frequent knee symptoms who walk with either a hybrid training system (HTS) that provides antagonist muscle electrical stimulation vs sensory transcutaneous electrical nerve stimulation (TENS). DESIGN Randomized, double-blinded, controlled trial. SETTING University-based fitness center. PARTICIPANTS Twenty-eight women (N=28) with obesity, aged 40-70 years, with daily knee symptoms. INTERVENTIONS Participants were randomized to 12 weeks of biweekly 30-minute walking exercise with either HTS (HTSW group) or sensory TENS (control group). MAIN OUTCOME MEASURES Pressure pain thresholds (PPTs) at the more symptomatic knee (local PPT) and PPT at the ipsilateral pain-free wrist (remote PPT). RESULTS After adjustment for preintervention values and body mass index (BMI), there was a statistically significant improvement in local PPT in the HTSW group compared with the control group (P=.039). After adjustment for pretraining value, age, and BMI, changes in remote PPT when comparing groups did not reach statistical significance, although the HTS group tended to demonstrate increased remote PPT (P=.052) compared with the control group. Moreover, after adjustment for pretraining value, knee pain, and quality of life, comparing groups did not reach statistical significance, although the HTS group tended to demonstrate decreased knee pain (P=.069) compared with the control group. CONCLUSIONS Augmentation of walking exercise with HTS was more effective than application of sensory TENS in improving local pain sensitivity at the knee but not at the wrist in women with obesity with frequent knee symptoms.
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Mobasheri A, Trumble TN, Byron CR. Editorial: One Step at a Time: Advances in Osteoarthritis. Front Vet Sci 2021; 8:727477. [PMID: 34336985 PMCID: PMC8322576 DOI: 10.3389/fvets.2021.727477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ali Mobasheri
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Department of Regenerative Medicine, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
- Departments of Orthopedics, Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
- Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- World Health Organization Collaborating Center for Public Health Aspects of Musculoskeletal Health and Aging, Université de Liège, Liège, Belgium
| | - Troy N. Trumble
- Veterinary Population Medicine, University of Minnesota Twin Cities, St. Paul, MN, United States
| | - Christopher R. Byron
- Department of Large Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, United States
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Kim M. Weight Control in Postmenopausal Korean Patients with Osteo-arthritis. IRANIAN JOURNAL OF PUBLIC HEALTH 2020; 49:2400-2408. [PMID: 34178747 PMCID: PMC8215065 DOI: 10.18502/ijph.v49i12.4828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Weight control is crucial for osteoarthritis management. This study investigated weight control methods in postmenopausal Korean osteoarthritis patients and examined their correlation with subjective health status and figure recognition, obesity, quality of life (QoL), and hemodynamic variables. Methods: One thousand six hundred and seventy-eight female postmenopausal osteoarthritis patients participated in the 2018 Korea National Health and Nutrition Examination Survey. A frequency analysis was conducted for weight control methods, and phi coefficients for crossover analyses or Cramer’s V coefficient were calculated to identify the relationships between weight-control-related variables and subjective health status and QoL. Using independent t-tests, we examined the relationships of weight control methods with hemodynamic variables. Results: Postmenopausal osteoarthritis patients’ preferred weight control methods were exercise, meal volume reduction, functional diet consumption, and the skipping of meals. Osteoarthritis patients who performed exercise demonstrated improved subjective figure recognition and health status, body weight, and recent 2-week discomfort, QoL, and hemodynamic variables (systolic blood pressure and fasting glucose, hemoglobin A1C, total cholesterol, high-density lipoprotein cholesterol, and high-sensitivity C-reactive protein [hs-CRP] levels). However, patients who attempted weight control by food volume reduction made relatively harder efforts to lose weight but were more likely to view themselves as obese, and demonstrated higher pain levels, anxiety/depression, and recent 2-week discomfort. Further, they exhibited lower triglyceride levels, as did patients who skipped meals. Conclusion: Overall, Korean postmenopausal osteoarthritis patients’ preferred weight control methods were exercise and reduced food intake. Although reduced food intake was effective for weight control, exercise improved mental health and hemodynamics, particularly inflammation (hs-CRP) levels.
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Affiliation(s)
- MunHee Kim
- Department of Health Science, Korea National Sport University, Seoul 05541, Republic of Korea
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Abstract
Evidence supports exercise as a first-line option for many chronic diseases. Although recommendations suggest 150 to 300 minutes a week of moderate-intensity or 75 to 150 minutes a week of vigorous-intensity aerobic activity, replacing sedentary behaviors with light-intensity activities reduces risks of all-cause mortality, and cardiovascular disease (CVD) mortality and incidence of CVD and type 2 diabetes mellitus. Exercise has positive effects on brain function, cognition, and depressive symptoms. Based on such evidence, health care providers should incorporate evaluation of physical activity into patient care. Patients should be evaluated for readiness and ability to exercise and encouraged to increase activity level.
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Affiliation(s)
- Leigh Ann McInnis
- School of Nursing, Middle Tennessee State University, 1500 Greenland Drive, Box 81, Murfreesboro, TN 37132, USA.
| | - Angela Morehead
- School of Nursing, Middle Tennessee State University, 1500 Greenland Drive, Box 81, Murfreesboro, TN 37132, USA
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Multicomponent Exercise Training Combined with Nutritional Counselling Improves Physical Function, Biochemical and Anthropometric Profiles in Obese Children: A Pilot Study. Nutrients 2020; 12:nu12092723. [PMID: 32899955 PMCID: PMC7551745 DOI: 10.3390/nu12092723] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 08/24/2020] [Accepted: 09/02/2020] [Indexed: 01/15/2023] Open
Abstract
Aerobics or strength exercise plus diet interventions have been shown to counteract childhood obesity. However, little is known with regard to periodized multicomponent exercise interventions combined with nutritional counselling, which might be less demanding but more enjoyable and respectful of children and adolescents’ nature. In order to analyze the impact of such a multimodal approach, 18 obese children (10.8 ± 1.6 years; 63% females; z Body Mass Index 3 ± 0.4) trained for 60 min, twice weekly and were measured for body composition, biochemical parameters and physical function. We found that 16 weeks of multimodal intervention (14 of training), based on fun-type skill-learning physical activities and physical conditioning with challenging circuits and games, together with nutritional counselling, led to an attendance > 80%, with significant overall health improvement. Body composition was enhanced (p < 0.01 for z BMI, mid-upper-arm-circumference, waist-to-height ratio, tricipital and subscapular skinfolds, body-fat % by Slaughter equation and Dual energy X-ray absorptiometry body fat% and trunk fat%), as well as metabolic profile (LDL cholesterol, gamma-glutamyl transferase , alanine aminotransferase ; p < 0.05), homeostatic model assessment of insulin resistance (HOMA-IR; p < 0.05) and inflammatory response (C-Reactive Protein; p < 0.05). Physical fitness was also improved (p < 0.01) through better cardiovascular test scores and fundamental movement patterns (Functional Movement Screen-7, FMS-4). Tailoring multimodal supervised strategies ensured attendance, active participation and enjoyment, compensating for the lack of strict caloric restrictions and the low volume and training frequency compared to the exercise prescription guidelines for obesity. Nutritional counselling reinforced exercise benefits and turned the intervention into a powerful educational strategy. Teamwork and professionals’ specificity may also be key factors.
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