Acta Pdiatrica ISSN 08035253

COMMENTARY

Exercise for the treatment of childhood obesity is it simply too much to ask?
Craig E Taplin, Phil Zeitler (zeitler.philip@tchden.org)
Department of Pediatrics, The Childrens Hospital, University of Colorado Denver, Aurora, CO, USA

Correspondence Professor Phil Zeitler, The Childrens Hospital Department of Endocrinology, 13123 E. 16th Avenue, Aurora, CO 80045, United States. Tel: 720-777-6128 | Fax: 720-777-7301 | Email: zeitler.philip@tchden.org Received 9 November 2008; accepted 14 November 2008. DOI:10.1111/j.1651-2227.2008.01165.x

The obesity epidemic that has spread across the western world over the last 20 years requires no introduction to the practicing paediatrician. It is, sadly, almost redundant to point to it as the defining modern issue; an issue where social and lifestyle trends intersect with the health of the population. The consequences will be pervasive, expensive and, yet, almost entirely preventable (13). The cause is axiomatic. Whether one can quote it verbatim or not, the law of conservation of energy is obvious to most. Energy can be neither created nor destroyed, only transferred or transformed. Energy can only be lost as a result of work done by a system upon its surroundings. The human body is the ultimate system, and in modern western societies we simply do not do enough work. Regrettably, our children are not immune. The anecdotal evidence is all around us. Screen time is increasing, and the seduction of the internet and gaming technology grows ever more irresistible to the young and old alike. Children no longer walk or bike to school in favour of being driven or riding the bus. Furthermore, schools, particularly in the United States, are being forced into sacrificing physical education to satisfy ever-increasing educational mandates and new agendas. Communities are changing, becoming more car-dependent and perceived by parents as less safe for children (4,5). As a consequence, the sights and sounds of children cheerfully burning calories as they play together in streets and parks after school are fading images from decades past. Exercise has become the pastime of the privileged, limited to those able to afford it. Yet, these are not just anecdotal observations. There is strong scientific evidence showing that sedentary activity correlates with obesity (6), that children are less active and
Invited commentary for Hagstromer M. Participation in organ ised weekly physical exercise in obese adolescents reduced daily physical activity.

burn fewer calories than once was the case, and that, as they progress from mid-childhood through adolescence, sedentary activity increases (710). Leaving aside overt dietary trends towards convenience and caloric density, it is self-evident that one of only two likely pathways towards reversing the childhood obesity epidemic is to intervene to increase physical activity. Such an obviously simple idea has so far been frustratingly difficult to prove effective at the population level. Exercise is wellknown to be beneficial to the overweight, obese and diabetic individual, but teasing out the effect of exercise alone has been difficult, with many intervention studies incorporating some form of education and dietary modification tools (11). Along with improving energy balance towards weight loss, exercise improves insulin sensitivity in obese children (12), lipid profiles (13,14) and may improve measures of psychosocial well-being (15). And yet, as paediatricians and endocrinologists are all too aware, exhorting children in the clinic to increase their exercise is seldom effective if their home and school environments remain unchanged. Meanwhile, achieving sustained improvements in weight after lifestyle intervention in the research setting has been similarly difficult, though Epstein and colleagues (16), along with others (17), have demonstrated weight loss with family and school-based interventions. Some of the difficulties are methodological. Protocols may have insufficient power or employ insufficiently sensitive outcome measures (18). Furthermore, biomarkers such as body fat and insulin sensitivity may be more important than weight per se when defining cardiovascular risk and progression to type 2 diabetes. Summerbell et al. reviewed randomized controlled trials of school-based obesity interventions from 1990 to 2005 (19). Overall, these most rigorous of school-based lifestyle intervention studies failed to show a sustained impact on weight status, though at least one was able to show an effect on reported physical activity (20).

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Exercise for the treatment of childhood obesity

In light of the difficulty in proving benefit when intervention is school-based, targeting children directly referred to the obesity clinic for exercise intervention is another obvious window of opportunity. However, when generalizing such studies to the general population, one must be cautious those patients motivated enough to attend a weight clinic are a self-selected group theoretically more likely to succeed. In addition, is there strong evidence that clinic-based exercise interventions even lead to sustained increases in physical activity, leaving aside weight loss as the outcome? And if exercise programmes for obese children do not change behaviour, why not? In this issue, Hagstromer and colleagues from Sweden explored the impact of an organized weekly exercise programme of 13 weeks duration in a clinic based setting (21). They recruited 47 obese adolescents and randomized them to either a 13-week programme of weekly group exercise sessions of varying activity including walking, cycling, swimming and strength training or to the control group. The authors aimed to explore the impact of the exercise intervention per se on activity levels after the conclusion of the study. Daily physical activity was assessed at baseline and then again after the conclusion of the study. Of note, only two thirds of the participants completed the study and were included in the data and, although the dropouts were not different at baseline, results with such small numbers of subjects and a high dropout rate must be treated with caution. These challenges experienced by the investigators underline the common difficulty in achieving adequate follow-up (in both obesity clinic and research settings), even in an arguably motivated group of patients such as these. The authors report that the exercise intervention actually decreased the subsequent activity levels of participants. After the completion of the structured exercise programme, those who completed the study went on to spend less time compared to baseline in low and moderate physical activity, and spent more time inactive, than did the control group who received no intervention and did not differ in their activity profiles from baseline. Its limitations notwithstanding, the study raises, but does not answer, some very interesting questions. Are children truly compensating for structured exercise by decreasing their activity at other times and how can this be addressed in future interventions? Is exercise just inherently difficult in this group of children? Are they embarrassed by issues of body image exacerbated by participation in and dressing for exercise? And, perhaps most interestingly, are there metabolic reasons to suspect that exercise is inherently more unpleasant in obese children than in children of normal weight? This has been shown in adults (22) and there is now emerging evidence that this is indeed the case in children too (23). Nevertheless, it remains a fundamental truth that successful and sustained increases in physical activity offer a clear pathway towards primary prevention of childhood obesity and secondary prevention of obesity-related complications, such as the metabolic syndrome and type 2 diabetes. The onus is on the medical community, as a matter of urgency,

to determine what barriers exist to the successful and sustained promotion of regular physical activity in children and to produce convincing evidence of its benefit in order to inform sound public health policy.

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