Makale 1

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obesity reviews doi: 10.1111/j.1467-789X.2007.00455.x
Effect of supervised exercise intervention on

metabolic risk factors and physical fitness in Chinese
obese children in early puberty
C. Chang1, W. Liu1, X. Zhao2, S. Li1 and C. Yu1
1
Institute of Sports Medicine, Peking Summary
University Third Hospital, 2Ba Yi Middle The aim of this paper was to study the effect of long-term supervised exercise-
School, Beijing, China induced weight maintenance on metabolic risk factors and physical fitness in
obese children in early puberty. A total of 49 obese children aged 12–14 years
Address for correspondence: C Chang, were divided into control and exercise groups. The children in the exercise group
Institute of Sports Medicine, Peking University accepted exercise intervention supervised by a professional sports teacher for 9 of
Third Hospital, Beijing 100083, China. E-mail: the 12 months. All participants in both groups received health education once
cuiqingchang@yahoo.com.cn every 3 months. Anthropometry and fasting serum lipids, glucose, insulin and
homeostatic model assessment for insulin resistance (HOMA-IR) were measured
at months 0, 3, 9, 12 of the intervention. Physical fitness was determined before
and after intervention. After the intervention (i) BMI was reduced by 0.6
(P < 0.05) in the exercise group, but increased by 0.5 (P < 0.05) in the control
group, compared with the pre-intervention level at the end of 9-month interven-
tion; (ii) Triglyceride levels in the exercise group significantly decreased by 23.1%
by 3 months (P < 0.05), and by 30.2% after 9 months (P < 0.05), but increased by
50% (P < 0.05) in the control group; high density lipoprotein-cholesterol
(HDL-C) decreased more by 35% (P < 0.05) in the controls than in the exercise
group (P < 0.05); (iii) Fasting serum glucose, insulin level and HOMA-IR
decreased, respectively, by 23.1%, 36.6% and 48.5% in the exercise group at
9 months (P < 0.05), whereas glucose levels increased by 10.9% (P < 0.05) in the
control group; (iv) Exercise performance, such as upper- and lower-limb strength,
flexibility and endurance, were enhanced by 17.9%, 12.3%, 22.3% and 20.4%
(P < 0.01), respectively and (v) At 12 months, i.e. 3 months after terminating the
supervised exercise, serum triglycerides, glucose, insulin and HOMA-IR level all
returned to the pre-intervention level. Supervised decrement exercise can effec-
tively slow the progress of obesity, improve insulin sensitivity and metabolic risk
factors, but once the supervised exercise is stopped, the health benefits weaken or
vanish. The key to helping these obese children is for them to cultivate good
exercise habits which are sustained throughout their lives.
Keywords: Exercise, insulin resistance, lipid, obesity.
obesity reviews (2008) 9 (Suppl. 1), 135–141
Obesity is highly correlated with a constellation of disor-

Introduction
ders, including insulin resistance, dyslipidemia and hyper-
Obesity is a significant public health issue in the world. The tension, hallmarks of the metabolic syndrome and the risk
prevalence and incidence of child and adolescent obesity of cardiovascular disease. Today’s overweight children and
have increased yearly in China (1) and deserve attention. adolescents are potentially setting the stage for increasing
© 2007 The Authors 135

Journal compilation © 2007 The International Association for the Study of Obesity. obesity reviews 9 (Suppl. 1), 135–141
1467789x, 2008, s1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2007.00455.x by Eskisehir Teknik Universitesi, Wiley Online Library on [05/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
136 Effect of supervised exercise on obese children C. Chang et al. obesity reviews
risks of cardiovascular disease, type 2 diabetes mellitus,

Health education and exercise intervention
cancer, osteoarthritis and premature all-cause mortality
later in life (2). Health education
It is known that the scientific and effective measures for All participants in the exercise and control groups received
prevention and treatment of child and adolescent obesity health education once per 3 months throughout the
are a rational diet, regular moderate exercise and improve- 12-month test periods, with advice on a balanced diet,
ments in their unhealthy lifestyle. Regular moderate physi- healthy eating behaviour, regular exercise and wellness.
cal activity is helpful for weight control and maintenance of According to Chinese Dietary Reference Intakes (4), the
weight loss, and for achieving health benefits as well, but recommended daily energy intake was about 9.196–
there are few studies examining the dose–effect of exercise 10.032 kJ (2200–2400 kcal) with a low-fat, high-fibre and
on health benefits and the effect of termination of exercise. enough-protein diet. The participants ate their diet ad
The aim of this study was to investigate the effects of a libitum during the whole intervention.
long-term supervised exercise intervention with weight loss
or maintenance on metabolic risk factors and physical
fitness in obese children and adolescents. Exercise intervention
Besides regular health education, the participants in the
exercise group received 9-months exercise intervention
Subjects and methods
supervised by professional exercise teacher in school. The
exercise items included running, basketball, standing long
Subjects
jump, rope skipping, taekwondo (a Korean traditional
A total of 65 obese children and adolescents (Han people) exercise), sit-and-up, push-up and throwing a heavy ball on
aged 12–14 years were enrolled, and received a complete weekdays, and mountain climbing or swimming at week-
physical examination before being divided into an exercise ends. Heart rate was measured and monitored to maintain
group (n = 33, 25 boys and 8 girls) and control group 145–160 beat min-1 during exercise. Table 2 sets out the
(n = 32, 24 boys and 8 girls) randomly according to their intensity, length and frequency of the exercise intervention
body mass index (BMI), but exceptionally, three boys and programme.
two girls in control group moved to the intervention group Anthropometry and fasting blood sample were taken
by their own choices. Twenty-five children (19 boys and 6 in the early morning before breakfast at months 0, 3, 9
girls) in the exercise group and 24 children(17 boys and 7 and 12.
girls) in the control group finished the 1-year test (Table 1).
None of the subjects were using drugs or therapies for
obesity, and none had a prior history of disease or injury
Anthropometry (4)
that would prevent daily exercise. The BMI criteria for
classifying obesity were those used for Chinese children Height was measured using a standard height meter
aged 7–18 years, i.e. where their BMIs were equal to or in attached to the wall. Weight and body fat percentage was
excess of the 95th percentile BMI for their sex-specific age measured by a Body Composition Analyser (model TBF-
groups (3). Consent to participate in the research pro- 300, Tanita Inc., Japan). Subjects were asked to be barefoot
gramme was obtained from both the subjects and their and wore a T-shirt and shorts. BMI was calculated. Waist
parents, and the project was approved by the Health circumference was measured using the method recom-
Science Center Ethics Committee of Peking University. mended by World Health Organization (4).
Table 1 The characteristics of subjects

Groups n Age (years) Height (cm) Weight (kg) Body mass index
Exercise
M 19 12.5 ⫾ 0.61 166.2 ⫾ 9.33 77.9 ⫾ 14.14 27.7 ⫾ 3.43
F 6 12.8 ⫾ 1.17 161.3 ⫾ 3.33 69.8 ⫾ 7.10 26.9 ⫾ 3.52
M+F 25 12.6 ⫾ 0.76 165.0 ⫾ 8.45 75.8 ⫾ 13.06 27.5 ⫾ 3.39
Control
M 17 12.3 ⫾ 0.77 162.4 ⫾ 6.87 72.8 ⫾ 13.89 27.4 ⫾ 3.58
F 7 12.9 ⫾ 0.38 158.6 ⫾ 3.78 66.0 ⫾ 6.04 26.2 ⫾ 2.26
M+F 24 12.2 ⫾ 0.07 161.5 ⫾ 6.43 71.3 ⫾ 12.75 27.1 ⫾ 3.32
© 2007 The Authors

obesity reviews Effect of supervised exercise on obese children C. Chang et al. 137
Table 2 Exercise intervention programme
Time (months) Exercise intensity Exercise mode Exercise duration Exercise frequency Exercise period
(min) (days per week) (weeks)
0–3 3–7 METs Aerobic exercise 60–90 5

12
Strength training 60 2
4–9 3–6 METs Aerobic exercise 30–40 4
24
Strength training 15–20 2
10–12 Stop supervised exercise training, but encourage exercise freely 12
MET, metabolic rate.
Determination of serum lipids, glucose, insulin, Results

homeostatic model assessment for
insulin resistance Physical characteristics
Total cholesterol (TC), triglycerides (TG), High density The mean heights and body weights of subjects in the two
lipoprotein and glucose level were measured using stan- groups were all increased significantly and continuously
dardized routine enzymatic colourimetric analysis kits (P < 0.01) during the whole 12-month intervention period.
separately (Biosino Biotechnology Company Ltd, China). At the end of the 9-month intervention, however, BMI
Low density lipoprotein (LDL) was calculated as described was reduced by 0.6 (P < 0.05) in the exercise group, but
by the Friedewald formula (5). Insulin was measured using increased by 0.5 (P < 0.05) in the control group. No dif-
a competitive radioimmunoassay kit (Beijing Atom High ferences were observed in either the waist circumference or
Tech Co. Ltd, China). The degree of insulin resistance was percentage body fat, although there were a tendency for a
determined by means of homeostatic model assessment decrease in the exercise group and an increase in the control
for insulin resistance (HOMA-IR). HOMA-IR insulin group. Three months after terminating the supervised exer-
resistance index was calculated by the follow formula: cise, BMI and waist circumference had all increased to a
HOMA-IR = fasting serum insulin (mU mL-1) ¥ fasting higher level than at the beginning of the study (P < 0.05) in
blood glucose (mmol L-1)/22.5. the exercise group, but were not significantly different from
the control group (Fig. 1).
Measures of physical fitness

Fasting serum lipids, glucose and insulin
Upper-limb strength was determined by the distance they
could throw a heavy ball, lower-limb strength by the length Metabolic data are summarized in Table 3 and Fig. 2. TG
of a standing jump, speed performance by 50-m-running levels in the exercise group significantly decreased by
time, endurance performance by 800-m running for the 23.1% by 3-month (P < 0.05) and by 30.2% at the end of
girls and 1000-m running for the boys, with flexibility the 9-month supervised exercise compared with pre-
performance assessed by the number of times of sitting and intervention values (P < 0.05). In the control group, TG
then moving to the upright position per minute. levels increased by 50% (P < 0.05) and high density lipo-
protein (HDL-C) decreased by 35% (P < 0.05), whereas in
the exercise group there seemed to be a delayed increase
which at 12 months was significantly different from the
Statistical analysis
controls (P < 0.05). TC and LDL-C level showed no sig-
Statistical analyses were performed with spss 14.0 nificant change in either the exercise or control groups.
software. All data were expressed as mean ⫾ SD unless Fasting serum glucose, insulin level and HOMA-IR
otherwise noted. Pre- and post-intervention values were decreased, respectively, by 23.1%, 36.6% and 48.5% in
compared by matched-paired t-tests for data with a normal the exercise group during the 9-month exercise intervention
distribution, and by matched-paired rank sum tests for data (P < 0.05). In the control group, however, the glucose
without a normal distribution. Accordingly, control and level increased by 10.9% (P < 0.05). Insulin level and
exercise values were compared by independent-sample HOMA-IR showed no change (Table 3).
t-test and rank sum test, respectively. A P-value of less than The prevalence rate of high TG (ⱖ1.7 mmol L-1)
0.05 was considered statistically significant. decreased from 12.5% (pre-intervention) to 8.3% after
© 2007 The Authors

(a) (b)
Exercise Control Exercise Control
84.0
172.0
82.0
170.0
80.0
Body weight (kg)

168.0 78.0
Height (cm)
166.0 76.0
74.0
164.0
72.0
162.0
70.0
160.0 68.0
158.0 66.0
64.0
156.0
0 3 9 12
0 3 9 12
Intervention time (months) Intervention time (months)
(c) (d)
Exercise Control Exercise Control
28.4 93.0
Waist circumference (cm)

28.2 92.0
28.0
Body mass index
91.0
27.8 90.0
27.6
89.0
27.4
27.2 88.0
27.0 87.0
26.8 86.0
26.6 85.0
26.4 84.0
26.2 0 3 9 12
0 3 9 12
Intervention Time (months)
Intervention time (months)
(e)
35.0 Exercise Control
Body Fat Percentage (%)
34.0
33.0
32.0
31.0
30.0
29.0
28.0
27.0
0 3 9 12
Intervention Time (months)
Figure 1 Anthropometric parameters in obese children (n = 25 in the exercise group, n = 24 in the control group) undergoing a 9-month supervised
exercise intervention and a subsequent 3-month post-exercise assessment. (a) Height; (b) Body weight; (c) Body mass index; (d) Waist
circumference; (e) Body fat percentage.
3-month intervention and to 0% at 9 months in the exer- to 29.4% over the whole 12-month period in the control
cise group, but increased from 18.2% before intervention group (Fig. 2).
to 25% at 9 months in the control group, i.e. double that of Three months after terminating the supervised exercise,
the exercise group (Fig. 2). The prevalence of high-fasting serum TG, glucose, insulin and HOMA-IR level, as well
serum glucose (ⱖ5.6 mmol L-1) decreased from 23.5% as the prevalence of hypertriglyceridema and hyperglyce-
before intervention to 9% at 3 months and to 0% at mia, all returned to the pre-intervention levels (Table 3,
9 months in the exercise group, but increased from 23.1% Fig. 2).
© 2007 The Authors

Table 3 Fasting serum lipids, glucose, insulin levels and HOMA-IR in obese children either in a control group or a group undergoing a 9-month
exercise intervention and then 3 months after terminating the exercise
Parameter Group Intervention time (months)
0 3 9 3 months after stopping

intervention
Triglycerides (mmol L-1) Exercise 1.3 ⫾ 0.67ab 1.0 ⫾ 0.60c 0.9 ⫾ 0.29c 1.5 ⫾ 0.73b
Control 1.0 ⫾ 0.50 1.5 ⫾ 0.67a
Total cholesterol (mmol L-1) Exercise 4.1 ⫾ 0.64 4.19 ⫾ 0.62 3.89 ⫾ 0.53 4.55 ⫾ 0.73
Control 4.3 ⫾ 0.84 4.5 ⫾ 0.72
LDL-C (mmol L-1) Exercise 2.4 ⫾ 0.62 2.7 ⫾ 0.55 2.4 ⫾ 0.52 2.7 ⫾ 0.73
Control 2.7 ⫾ 0.82 3.3 ⫾ 0.81
HDL-C (mmol L-1) Exercise 1.3 ⫾ 0.17 1.3 ⫾ 0.16 1.3 ⫾ 0.18 1.6 ⫾ 0.42*
Control 1.4 ⫾ 0.32 0.9 ⫾ 0.29a
Blood glucose (mmol L-1) Exercise 5.2 ⫾ 1.04a 5.0 ⫾ 0.28a 4.0 ⫾ 0.31b 5.4 ⫾ 0.65a
Control 4.6 ⫾ 0.80 5.1 ⫾ 0.91a
†
Insulin (mU L-1) Exercise 29.2 (8.9–59.1)a 23.7 (7.2–54.1)b 18.5 (7.2–56.4)c 39.7 (12.7–81.5)a
Control 37.6 (24.1–92.5) 43.8 (12.6–99.9)
†
HOMA-IR Exercise 6.8 (1.8–15.6)a 5.2 (1.6–12.5)b 3.5 (1.2–9.6)c 9.8 (2.7–16.1)a
Control 7.5 (4.2–21.4) 10.8 (3.2–27.4)
All data are expressed as mean ⫾ SD unless otherwise noted (n = 24 in exercise group, n = 20 in control group).
The data for each parameter without a common superscript letter are significantly different (P < 0.05), comparing within the same group.
*P < 0.05, compared with control group.
†
Date are expressed as median (min–max).
HDL-C, high density lipoprotein; HOMA-IR, homeostatic model assessment for insulin resistance; LDL-C, low density lipoprotein.
(a) (b)
25 exercise control 30 exercise control
25
Prevalence of
Prevalence of high
20
high TG (%)
glucose (%)
20
15
Figure 2 (a) the prevalence of high TG 15
10
(= 1.7 mmol L-1) and (b) high glucose 10
(= 5.6 mmol L-1) in obese children undergoing 5 5
a 9-month exercise intervention and at 0 0
12 months, 3 months after terminating the 0 3 9 12 0 3 9 12
exercise. Intervention time (months) Intervention time (months)
duced significant improvements in metabolic syndrome

Physical fitness
and cardiovascular risk factors (9–11). The findings of this
After 9 months of supervised exercise, all the different study provide evidence that, in obese adolescents, super-
exercise tests improved significantly (P < 0.01), and upper- vised weight-reducing exercise may (i) effectively prevent
and lower-limb strength, flexibility and endurance were and slow the deterioration of obesity; (ii) improve the lipid
enhanced by 17.9%, 12.3%, 22.3% and 20.4%, respec- and glucose metabolic profiles and insulin resistance and
tively. The exception was the 50-m-running time which (iii) strengthen physical fitness. The positive effects of exer-
showed no significant change (Table 4). cise may weaken and/or vanish after 3 months of stopping
exercise with the exception of HDL, which showed no
change.
Discussion
During the first 9-month period of supervised exercise
We have seen a rapid rise in obesity rates in recent years, intervention, BMI was significantly reduced in the exercise
with a concomitant increase of children exhibiting charac- group, but increased in the control group. Waist circumfer-
teristics of the metabolic syndrome (6–8). Pre-puberty and ence and percentage body fat showed no significant change,
early puberty is one of the major stages of normal body fat although there was a tendency for them to reduce in the
accumulation, and obesity may become highly prevalent exercise group and to increase in the control group. The
at this time. Some studies in young groups using a short moderate aerobic exercise and strength training are prob-
residential diet and activity intervention programme pro- ably responsible for the decrease in BMI, and the results of
© 2007 The Authors

Table 4 Exercise performance of obese children undergoing a 9-month exercise intervention
Throwing a heavy ball Standing jump Times of sit-and-up Time for a 50-m 800/1000-m
(cm) (cm) per minute running (s) running time (min)
Pre-intervention 636.4 ⫾ 167.8 162.9 ⫾ 23.5 30.4 ⫾ 11.0 9.49 ⫾ 1.24 6.2 ⫾ 1.7
Post-intervention 750.0 ⫾ 138.3* 183.0 ⫾ 26.5* 36.6 ⫾ 8.6* 9.01 ⫾ 1.02 4.8 ⫾ 0.7*
Difference 113.6 (17.9%) 20.1 (12.3%) 6.2 (20.4%) -0.38 (P = 0.059) -1.4 (22.3%)
All data are expressed as mean ⫾ SD (n = 22).

*P < 0.01, compared with pre-intervention level.
continuous 3-day dietary surveys showed the daily energy was modestly reduced by exercise, whereas in the control
intake was not significantly different between the exercise group there was a progressive increase in waist circumfer-
and control groups (8.62 ⫾ 2.41 kJ vs. 8.48 ⫾ 2.48 kJ). ence even when BMI was on average little changed (see
This study supports the evidence that exercise is very Fig. 1). The marked reduction in the prevalence of high-
important in preventing the progression of obesity in fasting serum glucose from 23.5% to 0% is in-keeping with
adolescents. exercise increasing insulin receptor auto-phosphorylation,
The marked improvements in fasting serum TG, HDL-C, glucose transporter 4 expression and glucose transport
glucose and insulin reflect the impact of the estimated (14–16).
improvements in insulin sensitivity. The serum TG was, as The exercise not only improved the measures of obesity
expected, marked and evident within the first 3 months and the metabolic risk factors, but also improved the physi-
with moderate exercise, and remained at the lower level in cal fitness in terms of endurance, strength and flexibility of
the next 6 months, when the exercise level was performance, with the exception of sprinting times. Half of
more modest but still associated with a further decline in our subjects in the exercise group developed the exercise
insulin resistance. Thus, the prevalence of high TG habit and kept on doing regular exercise on their own when
(ⱖ1.7 mmol L-1) decreased from 12.5% to 8.3% initially, the supervision stopped. The other half, however, seemed
but then dropped to 0% after 9 months. The decrease in to need the continued stimulation and supervision, because
insulin resistance may play an important role in reducing they rapidly give up their exercise and went back to their
TG (Table 3). The results indicate that once established inactive lifestyle.
regular but modest exercise can improve dyslipidaemias. The demonstration that the BMI, serum TG, glucose,
The absence of change in serum TC and LDL-C probably insulin and HOMA-IR level all returned to pre-intervention
reflects the fact that in practice, the children’s dietary fat levels after 3 months of stopping the supervised exercise
intake did not change: improvement in serum cholesterol emphasizes the importance of maintaining the level of
levels also needs more exercise and physical activity (2.5– physical activity used in the second phase of our interven-
4.5 h d-1)(9–11). The data, however, suggest that a suitable tion study, and re-emphasizes the need to prevent obesity
ad libitum diet and relatively low amounts of physical and metabolic syndrome in children by helping them to
activity may be more sustainable in this obese population; formulate an active lifestyle and a good habit of exercise, so
prolonged times of exercise may not be required to achieve that the health benefits can be sustained throughout their
significant metabolic benefits. The present study found future lives.
that the serum HDL-C in exercise group was maintained In summary, the results of this study in obese adolescents
despite a reduction in BMI, and showed the characteristic document that supervised weight-limiting exercise in two
slow response to exercise with an increase by 12 months, stages over a 9-months period can effectively slow down
whereas in the control group HDL-C was significantly the progress of obesity, improve insulin sensitivity and
lower – which indicates that regular moderate exercise can the associated factors of metabolic syndrome, as well as
induce progressively accumulating health benefits. enhancing physical fitness. After stopping the supervised
Insulin resistance, considered to be at least partially exercise for 3 months, the health benefits achieved from
modulated by visceral and intramuscular lipid accumula- exercise may weaken or disappear subsequently. Obesity
tion (12), is considered to be an underlying cause for the and physical inactivity are associated with each other not
risk factors of the metabolic syndrome (13). Thus in only in childhood (17), but also more importantly, they are
the present study, where there was a large decrease in often carried over into adulthood and increase the risks
HOMA-IR (48.5%) suggestive of increased insulin sensi- of cardiovascular disease and future chronic diseases. If
tivity, the exercise probably contributed to this insulin sen- sustained, the lifestyle modification achieved in this study
sitivity by reducing both muscle and liver fat accumulation. could help mitigate chronic diseases-related complications
It is therefore not surprising that the waist circumference in the future.
© 2007 The Authors

9. Chen AK, Roberts CK, Barnard RJ. Effect of a short-term diet

Acknowledgements and exercise intervention on metabolic syndrome in overweight
children. Metab Clin Exp 2006; 55: 871–878.
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Peking University. resistin and cardiovascular risk factors in obese persons. Chin J
Sports Med 2006; 25: 399–403.
11. Sudi KM, Gallistl S, Trobinger M. The effects of changes in
Conflict of Interest Statement body mass and subcutaneous fat on the improvement in metabolic
All authors declare no conflicts of interests. risk factors in obese children after short-term weight loss. Metabo-
lism 2001; 50: 1323–1329.
12. Weiss R, Dufour S, Tadsali SE. Prediabetes in obese youth: a
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1467789x, 2008, s1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2007.00455.x by Eskisehir Teknik Universitesi, Wiley Online Library on [05/01/2023].

Effect of supervised exercise intervention on

C. Chang1, W. Liu1, X. Zhao2, S. Li1 and C. Yu1

Keywords: Exercise, insulin resistance, lipid, obesity.

obesity reviews (2008) 9 (Suppl. 1), 135–141

Obesity is highly correlated with a constellation of disor-

© 2007 The Authors 135

risks of cardiovascular disease, type 2 diabetes mellitus,

Table 1 The characteristics of subjects

© 2007 The Authors

Table 2 Exercise intervention programme

0–3 3–7 METs Aerobic exercise 60–90 5

MET, metabolic rate.

Determination of serum lipids, glucose, insulin, Results

Measures of physical fitness

© 2007 The Authors

Body weight (kg)

Waist circumference (cm)

Intervention Time (months)

© 2007 The Authors

Parameter Group Intervention time (months)

0 3 9 3 months after stopping

duced significant improvements in metabolic syndrome

© 2007 The Authors

Table 4 Exercise performance of obese children undergoing a 9-month exercise intervention

All data are expressed as mean ⫾ SD (n = 22).

© 2007 The Authors

9. Chen AK, Roberts CK, Barnard RJ. Effect of a short-term diet

© 2007 The Authors

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