Effects of physical exercises and nutritional guidance on the cardiovascular risk profile of obese children.
ABSTRACT OBJECTIVE: To analyze the effects of a supervised physical exercise and nutritional guidance program, conducted with a playful basis, on the cardiovascular risk profile of obese children. METHODS: Forty-four children aged between 8 and 11 years, divided into two groups, were paired by gender and age: intervention group (n = 22) and control group (n = 22). The following parameters were measured before and after the intervention: body mass, height, waist circumference, total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, fasting glucose, high-sensitive C-reactive protein, blood pressure, and carotid intimamedia thickness. Both groups continued their traditional medical treatment. The case group exercised with recreational activities three times a week during 12 weeks, and participated in a weekly nutritional guidance session. The control group did not participate in the intervention described. Descriptive statistics, paired and unpaired Student's t-test, Mann-Whitney's U test, and the Wilcoxon test were used, with a significance level of p < 0.05. RESULTS: 32 children concluded the study (16 in each group). At the end of the study, the case group showed a significant reduction in the body mass index (BMI) (p = 0.001), total cholesterol (p = 0.001), LDL cholesterol (p = 0.001), diastolic blood pressure (p = 0.010), and average (p = 0.003) and maximum (p = 0.002) carotid intima-media thickness. The control group showed a significant increase in waist circumference (p = 0.001), blood glucose (p = 0.025), C-reactive protein (p = 0.016), a reduction of HDL cholesterol (p = 0.012) and total cholesterol (p = 0.042), and an increase in the average (p = 0.012) and maximum (p = 0.024) carotid intima-media thickness. CONCLUSION: The program proved effective in the reduction of obesity indicators and of the intima-media thickness, a direct and early signal of atherosclerosis.
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ABSTRACT: The present study aimed to investigate whether obese children improve their balance and postural performance following a 6-month-weight management program. Twenty-nine obese children aged 6-14 years were examined posturographically before and after participation in weight management program. The interactive balance system evaluated the stability index, Fourier spectral analysis, weight distribution index, and falling index. The performance was evaluated for eight positions requiring closure of eyes, standing on pillows, as well as head turns. Anthropometric measurements (e.g., weight, height, BMI, and BMI percentiles) were also determined before and after the intervention. We found significant increase in height and significant decreased in BMI percentile following the intervention program (p < .05). Pre-intervention BMI percentile was found to be correlated with stability index in most of the positions measured (e.g., normal open position = .464; p = .011). Following the intervention program, an interaction was found between BMI percentile differences (pre- versus post-interventional) and balance (stability index and F2-F4 frequencies of most standing positions). Furthermore, a correlation was found between general stability and the falling index (.446; p = .015). Regression analysis showed that only initial weight distribution index and post-intervention BMI entered the equation as predictors of post-intervention weight distribution index. Conclusion: Weight management program for childhood obesity improved stability, reduced potential vestibular stress/disturbances, and decreased falling probability of the participants. Further longitudinal studies are needed to verify the relationship between physical activity, weight loss, and reduction of subsequent injuries in obese children.European Journal of Pediatrics 07/2013; · 1.98 Impact Factor
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ABSTRACT: Educative strategies need to be adopted to encourage the consumption of healthy foods and to promote physical activity in childhood and adolescence. The effects of recreational physical activity and a health-habit orientation program using an illustrated diary on the cardiovascular risk profile of overweight and obese children was investigated. The weight and height of 314 schoolchildren aged between 9 and 11 years old, in a public school in Brasilia, Federal District, Brazil, were recorded. According to the body mass index (BMI) classification proposed by the World Health Organization, 84 were overweight or obese for their age and sex. Of these children, 34 (40%) participated in the study. Students were divided into two groups matched for sex, age, BMI, percent body fat (%BF): the intervention group (IG, n = 17) and the control group (CG, n = 17). The IG underwent a program of 10 weeks of exercise with recreational activities and health-habit orientation using an illustrated diary of habits, while no such interventions were used with the CG during the study period. Before and after the intervention, the children's weight, height, BMI, %BF, waist circumference (WC), maximum oxygen intake (VO2max), total cholesterol (TC), high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides, glucose, eating habits, and physical activity level (PAL) were assessed. In analyzing the data, we used descriptive statistics and paired and unpaired t-tests, using a significance level of 0.05. For assessment of dietary habits, a questionnaire, contingency tables, and the chi-squared test were used, with <0.05 set as the significance level. After 10 weeks of intervention, the IG showed a reduction in BMI (pre: 22.2 ± 2.1 kg/m(2) versus [vs] post: 21.6 ± 2.1 kg/m(2), P < 0.01); WC (pre: 70.1 ± 6.1 cm vs post: 69.1 ± 5.8 cm, P < 0.01); %BF (pre: 29.2% ± 4.6% vs post: 28.0% ± 4.8%, P < 0.01); systolic blood pressure (P < 0.01); VO2max (P = 0.014); TC (P < 0.01); LDL (P < 0.01); triglycerides (P < 0.01); and intake of candy (P < 0.01) and soda drinks (P < 0.01), while an increase in the consumption of fruit (P < 0.01) and PAL (P < 0.01) were observed. The CG did not show any change in the health parameters assessed. The program was effective in reducing risk factors for cardiovascular disease and the use of an illustrative diary may have been the key to this result, since students were motivated to change their poor eating habits and to increase their physical activity level.Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 01/2013; 6:445-451.
REV ASSOC MED BRAS. 2013; 59(1):56-63
ASSOCIAÇÃO MÉDICA BRASILEIRA
Effects of physical exercises and nutritional guidance on the
cardiovascular risk profile of obese children☆
Lisiane Schilling Poetaa,*, Maria de Fátima da Silva Duarteb, Bruno Caramellic,
Jorge Motad, Isabela de Carlos Back Giulianoe
a Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
b Postgraduate Program in Physical Education, UFSC, Florianópolis, SC, Brazil
c Postgraduate Program in Cardiopneumology, Instituto do Coração, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil
d Universidade do Porto, Porto, Portugal
e Department of Pediatrics, Postgraduate Program in Public Health, UFSC, Florianópolis, SC, Brazil
Received 28 May 2012
Accepted 14 August 2012
☆Study conducted at the Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
*Corresponding author at: Laboratório de Desenvolvimento Humano, Rua Pascoal Simone, 358 – Coqueiros, 88080-350 – Florianópolis,
E-mail address: firstname.lastname@example.org (L.S. Poeta)
0104-4230/$ – see front matter © 2013 Elsevier Editora Ltda. All rights reserved.
A B S T R A C T
Objective: To analyze the effects of a supervised physical exercise and nutritional guidance
program, conducted with a playful basis, on the cardiovascular risk profile of obese children.
Methods: Forty-four children aged between 8 and 11 years, divided into two groups, were
paired by gender and age: intervention group (n = 22) and control group (n = 22). The
following parameters were measured before and after the intervention: body mass, height,
waist circumference, total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides,
fasting glucose, high-sensitive C-reactive protein, blood pressure, and carotid intima-
media thickness. Both groups continued their traditional medical treatment. The case
group exercised with recreational activities three times a week during 12 weeks, and
participated in a weekly nutritional guidance session. The control group did not participate
in the intervention described. Descriptive statistics, paired and unpaired Student’s t-test,
Mann-Whitney’s U test, and the Wilcoxon test were used, with a significance level of p < 0.05.
Results: 32 children concluded the study (16 in each group). At the end of the study, the
case group showed a significant reduction in the body mass index (BMI) (p = 0.001), total
cholesterol (p = 0.001), LDL cholesterol (p = 0.001), diastolic blood pressure (p = 0.010), and
average (p = 0.003) and maximum (p = 0.002) carotid intima-media thickness. The control
group showed a significant increase in waist circumference (p = 0.001), blood glucose
(p = 0.025), C-reactive protein (p = 0.016), a reduction of HDL cholesterol (p = 0.012) and total
cholesterol (p = 0.042), and an increase in the average (p = 0.012) and maximum (p = 0.024)
carotid intima-media thickness.
Conclusion: The program proved effective in the reduction of obesity indicators and of the
intima-media thickness, a direct and early signal of atherosclerosis.
© 2013 Elsevier Editora Ltda. All rights reserved.
REV ASSOC MED BRAS. 2013; 59(1):56-63
Obesity is a chronic and currently epidemic disease whose
prevalence increased in the last decades in various countries,
In addition to the high prevalence, the relevance
of childhood obesity has been increasing due to its
association with several morbid conditions, such as
diabetes mellitus type 2, systemic arterial hypertension,
dyslipidemia, and atherosclerosis complications in
adulthood.3,4 Early endothelial dysfunction in obese
children and adolescents, in which the carotid intima-
media thickness is significantly greater than those with
normal weight, is also described.5
The relationship between obesity and metabolic
syndrome appears to be especially important in childhood,
since excess weight has been considered a predisposing
factor for this syndrome even at this age, diagnosed in
approximately 40% of obese children.6 Metabolic syndrome
comprises the grouping of cardiovascular risk factors,
such as arterial hypertension, central deposition of body
fat, dyslipidemia, and insulin resistance.7 Its importance
in children and adolescents is increasing due to the
association with early signs of myocardial damage and
As a basic component of prevention and treatment of
obesity, the early adoption of a healthy lifestyle should
be considered, such as a balanced diet and regular
practice of physical activities, preferably from childhood
onwards.9 In addition to the benefits of the prevention
and treatment of diabetes associated with obesity and
of metabolic syndrome,10 regular physical exercises
may also significantly improve the metabolic profile as
an independent effect, even when the patient remains
Physical exercise programs and nutritional guidance
have been proved effective in the treatment of obesity and
improvement of the lipid profile of obese adolescents.12
However, when working with children, structured physical
exercise programs, although effective, may be less
welcoming, receiving lower adherence. Hence, physical
exercises with recreational activities, due to being fun,
may increase participation and adherence to the proposed
activities during childhood, and may be a predictive factor
for maintenance of regular physical activities during
adolescence and adulthood.
Evidence regarding the efficiency of supervised
interdisciplinary programs for obese children appears to
still be fairly scarce, especially in Brazil, mainly regarding
the effects on the thickness of the carotid artery after
Efeitos do exercício físico e da orientação nutricional no perfil de risco
cardiovascular de crianças obesas
R E S U M O
Objetivo: Analisar os efeitos de um programa de exercício físico e orientação nutricional
supervisionado, de caráter lúdico, no perfil de risco cardiovascular de crianças obesas.
Métodos: Quarenta e quatro crianças com idades entre 8 e 11 anos divididas em dois grupos
pareados em sexo e idade: grupo intervenção (n = 22) e controle (n = 22). Mensurou-se,
antes e após a intervenção, a massa corporal, estatura, perímetro abdominal, colesterol
total, HDL-colesterol, LDL-colesterol, triglicérides, glicemia de jejum, proteína C reativa
ultrassensível, pressão arterial e espessura médio-intimal carotídea. Ambos os grupos
continuaram com acompanhamento médico tradicional. O grupo caso participou de 12
semanas de exercício físico, com atividades recreativas em três sessões semanais e uma
sessão semanal de orientação nutricional. O grupo controle não participou da intervenção
descrita. Na análise foram utilizados a estatística descritiva, o teste t pareado e o teste
não pareado, o teste U de Mann Whitney e o teste do Wilcoxon, adotando-se nível de
significância p > 0,05.
Resultados: Trinta e duas crianças completaram o estudo (16 em cada grupo). Ao final, o
grupo caso apresentou redução significativa no índice de massa corporal (IMC) (p = 0,001),
colesterol total (p = 0,001) e LDL-colesterol (p = 0,001), pressão arterial diastólica (p = 0,010)
e espessura médio-intimal média (p = 0,003) e máxima (p = 0,002). O grupo controle
apresentou aumento significativo no perímetro abdominal (p = 0,001), glicemia (p = 0,025),
proteína C reativa (p = 0,016) e redução do HDL-colesterol (p = 0,012) e colesterol total
(p = 0,042) e aumento na espessura médio-intimal média (p = 0,012) e máxima (p = 0,024).
Conclusão: O programa foi efetivo na redução dos indicadores de obesidade e na diminuição
da espessura médio-intimal, um sinal indireto e precoce da aterosclerose.
© 2013 Elsevier Editora Ltda. Todos os direitos reservados.
REV ASSOC MED BRAS. 2013; 59(1):56-63
interventions in children. Previous studies found positive
effects of physical exercises through recreational activities
and nutritional guidance on the components of the
metabolic syndrome;13 and in reducing excess weight, fat
body mass, abdominal perimeter, and blood pressure14 of
Given the outlined shortcomings, this study aimed to
analyze the effects of a supervised physical exercise and
nutritional guidance program, conducted with a playful
basis, on the cardiovascular risk profile of obese children.
This was a controlled clinical test. The initial population of the
study encompassed children aged between 8 and 11 years old
and with a body mass index (BMI) above the 95th percentile
according to criteria of the National Center for Health
Statistics (NCHS).15 Children were recruited consecutively at
the cardiology and pediatric endocrinology outpatient clinic of
the Hospital Infantil Joana de Gusmão (HIJG) in Florianópolis/
SC, Brazil (state reference center for this disease) during the
period from January to July, 2009. Inclusion criteria were: obese
children aged between 8 and 11 years old, attended to at the
clinic, and resident in Florianópolis/SC. Exclusion criteria
were: participation in any type of structured interdisciplinary
program for weight loss; or having any physical or mental
disability that impaired participation in the program. All
children who met the inclusion criteria and sought assistance
in this period were invited by the institution’s physicians
to participate in the study. Also, posters about the program
were attached to the institution’s entrance hall, with a
telephone number for contact. During the recruitment period,
approximately 120 obese children aged between 8 and 11 years
old were attended to at the outpatient clinic; 90 of them met
the inclusion criteria.
Seventy-seven parents/guardians demonstrated interest
in the participation of their children in the program. Of
these children, 32 studied during the morning, and 45
during the afternoon. Due to the infrastructure available
in Universidade Federal de Santa Catarina (UFSC) Sports
Center, the program was developed during the afternoon.
Therefore, children that studied during the morning were
allocated to the intervention group (n = 32), and those
who studied during the afternoon, to the control group
(n = 45). Losses from the first contact until the beginning
of the program amounted to ten in the intervention
group, and 23 in the control group. Thus, each group
initially comprised 22 children (11 females and 11 males
per group), amounting to 44 obese children classified by
age and gender. Children from the control group did not
participate in the intervention, except for the traditional
medical monitoring. All children, from both groups, were
instructed to keep their regular activities during the study
period, and received guidelines from the HIJG medical team,
or from other units that monitored them, regarding the
maintenance of an active life style activities and healthy
eating habits during the monitoring, as is usually done in
the treatment of obesity at any age.
To calculate the size of the sample, a clinically
significant difference of systolic blood pressure of 15 mmHg
and standard deviation of 15 mmHg of the population of
obese children in Florianópolis,SC (Brazil) were considered,
with error type I of 5% and error type II of 20%, as it is the
risk factor that first causes cardiovascular repercussions in
childhood and adolescence.8
Considering these parameters, the minimum size of
the sample would be 16 individuals in each group. To this
number, 25% were added to account for potential losses
and refusals; the resulting number coincides with the
number of children that intend to participate.
After the beginning of the program, the following
exclusion criteria were adopted: children from the case
group that did not attend at least 90% of the sessions16
and whose caretaker did not participate in the nutritional
guideline sessions; and children from the control group
whose case group pairs quit the intervention or were
excluded from the analysis.
All children were submitted to valuations at HIJG in
the morning, from 7:30 a.m. to 12:00 p.m., until one week
before and one week after the beginning and termination,
respectively, of the intervention program.
In order to characterize the sample, a pre-coded
questionnaire with questions regarding socio-demographic
and clinical aspects was completed by the child caretaker.
Additionally, information regarding sexual maturity was
also collected through self-evaluation, pursuant to Tanner’s
stages of maturity;17 this study considered information
related to pubic hair on both genders.
To measure the body mass, a 150 kg digital scale with an
accuracy of 100 grams was used. The scale was calibrated
before measuring, and the children were weighed standing,
barefoot, wearing only shorts and shirts. A portable
stadiometer was used to measure their height; it was
mounted on a wall without baseboard and had a scale and
resolution of 1 mm, using the vertex and the plantar region
as reference points.18 BMI was determined by the formula
body mass (kg) divided by the square of height (m). Waist
circumference was measured using a measuring tape with
scale of 1 mm. The tape was placed above the iliac crest,
parallel to the floor, with the individual standing with a
relaxed abdomen, arms along the body, and feet close
together. All anthropometric measurements were taken
twice, always by the same evaluator, and were repeated in
case of disagreement.
While measuring total cholesterol and fractions,
triglycerides, blood glucose, and high sensitivity C-reactive
protein, venous blood (4 mL) was also collected, observing
12-hour fasting. Total cholesterol and triglycerides were
determined using the enzymatic method (SHOD-PAP,
Merck®). HDL-cholesterol was determined directly after
REV ASSOC MED BRAS. 2013; 59(1):56-63
precipitation of other lipoproteins.19 LDL-cholesterol was
calculated using the formula proposed by Friedewald
et al.20 Blood glucose levels were determined by
the enzymatic method (glucose oxidase). C-reactive
protein levels were determined using a highly sensitive
Systemic blood pressure was assessed through the
auscultator method, with a mercury sphygmomanometer
and cuff adjusted to the mid-upper arm circumference,
pursuant to international guidelines. Two right arm measures
were taken by an experienced physician: after five minutes
of rest in the supine position and again approximately 25
minutes after the first measure, repeating another measure
if the results of the previous two measures were above the
90º percentile for age, gender, and height.
All measures were taken approximately one hour after
blood collection. A snack was served after blood collection
and at least one hour before the measurements of blood
pressure. For analysis purposes, the average of the two or
three measurements was used.
The carotid intima-media thickness was assessed by a
cardiologist, using a GE (Connecticut, USA) device, the Vivid i®
model, with a 12-MHz linear transducer. Six pictures of
each individual were taken, with a longitudinal view of the
carotid bulb in arterial diastole, with the three clearest images
subsequently selected. Each image was digitally read offline
to determine the average and maximum carotid intima-
media thicknesses. The average of the average values from
each image, and the average of the maximum values from
each image were calculated.
Intervention ProgramCardiometabolic Intervention
Program in Obese Children Applied with a Playful
and Interdisciplinary Basis (Programa de Intervenção
Cardiometabólica em Crianças Obesas, Lúdico e
Interdisciplinar – PICCOLI)
The intervention program consisted of physical exercises
with playful activities and nutritional guidance for 12
Physical exercises took place in a gymnasium and on a field
(twice a week) and in a pool (once a week), all located at UFSC
Sports Center – CDS (Brazil). The exercises were performed in
three weekly sessions, with the duration of 60 minutes each,
amounting to 36 sessions. Each session consisted of stretching/
warming up (5-10 minutes), a main part – aerobic physical
activities (40-45 minutes), and relaxation (5-10 minutes). The
exercises were previously prepared and developed by two
professional physical educators, and consisted of recreational
activities (e.g.: walking, running, circuit training, pre-sporting
games, trampoline games, jump rope, dancing, and swimming
pool activities) with a moderated to vigorous intensity.13,16
Activities were carried out aiming at achieving an intensity
of 65% to 85% of the maximum heart rate,16 indirectly
determined by the formula (maximum heart rate = 208 – 0.7
x age).22 The heart rate was individually monitored, through a
Polar (S610i) heart rate monitor, during all activities, to ensure
its maintenance within the recommended range. After the
exercises, monitor data were analyzed and transferred to a
Polar computer program (S620i). At the end of all sessions,
orientations on the importance of regular physical exercises
The nutritional guidance was provided by a nutritionist
and a group of UFSC nutrition students, and consisted
of weekly meetings with parents and children, with
educational and informative purposes, aiming to
encourage them to adopt healthier eating habits. In these
meetings, lectures on nutritional guidance were given
using the Brazilian food pyramid23. After explanations,
the participants were encouraged to play games and fun
activities related to the theme.
In order to analyze the data obtained, descriptive
statistics procedures were initially performed, with
the calculation of the average and standard deviation
in variables with parametric distribution, and median
and interquartile range in those with non-parametric
distribution. Paired and unpaired Student’s t-test were used
for data with regular distribution; Mann-Whitney’s U test
and the Wilcoxon test were used in variables with non-
regular distribution. All statistical analyses were performed
using the Statistical Package for Social Sciences (SPSS) 17.0,
adopting a significance level p < 0.05, accepting that all
tests were two-tailed.
This study was approved by the Research Ethics Committee
of the UFSC (protocol No. 302/08). All persons responsible for
the children were previously informed about the objective and
design of the study, and those who accepted to participate
signed an informed consent. All children were submitted to
medical evaluation prior to being accepted in the research.
After the end of the study, all children continued to receive
medical care from the original service.
Of the 44 children (22 in each group) that initiated the study,
there was a loss of six children in the intervention group,
and the study was concluded with 32 children (16 in each
group). As the individuals were paired, their respective
pairs from the control group were excluded. There was
no significant difference between the individuals who
concluded or abandoned the study (p > 0.05).
The average age in the intervention group was 9.6
years and in the control group was 9.4 years (p = 0.625).
All children were students from public schools of
Florianópolis/SC, had physical education classes three
times a week, were at the prepubescent or pubescent
stage of maturity, and most belonged to families with a
monthly income between two and five minimum wages.
In the intervention group, the time spent watching TV or
using the computer was 3.6 ± 1.8 hours/day, and in the
control group the time was 3.1 ± 1.5 hours/day (p = 0.460).
In the intervention group, one child was medicated for
REV ASSOC MED BRAS. 2013; 59(1):56-63
dyslipidemia and one for gastroesophageal reflux disease.
In the control group, one child was medicated for arterial
hypertension, one for depression, and one for bronchial
asthma. The other children in the groups did not take
medications on a regular basis.
The comparative analysis of initial anthropometric and
metabolic parameters demonstrated that there were no
statistically significant differences between the groups
in the pre-test (unpaired t-test or Mann-Whitney’s test).
However, the post-test showed that groups differed as to
systolic blood pressure (p = 0.003), diastolic blood pressure
(p = 0.025), C-reactive protein (p = 0.002), and average
intima-media thickness (p = 0.018), with lower values in the
intervention group, representing more satisfactory results.
Table 1 presents the impact of the intervention
program on the anthropometric and metabolic profile.
The intervention group showed significant reduction in
BMI, total cholesterol, LDL-cholesterol, and diastolic blood
pressure after the end of the program. No significant
differences were observed regarding the remaining
variables. Conversely, the control group presented a
significant increase in waist circumference and in fasting
glucose, as well as a reduction in HDL-cholesterol and in
total cholesterol (Table 1). Data in the table indicate that
the reduction in total cholesterol was observed in both
groups; however, the reduction was almost twice as high
in the intervention group when compared to the control
group. Four children in the intervention group changed
from the classification “obesity” to “overweight” by the
end of the program.
Table 2 presents the results regarding the intima-media
thickness, triglycerides, and C-reactive protein before and
after the intervention. Significant changes regarding the
average and maximum carotid intima-media thickness
were found in the intervention group; while in the control
group, there was a statistically significant increase in both
average and maximum carotid intima-media thickness.
No significant improvements were verified in other
parameters analyzed after intervention in the case group.
The control group showed an increase of the C-reactive
protein in the post-test.
The results of this study evidenced the positive effects of the
program on the cardiovascular risk profile of obese children,
especially in the reduction of the BMI, total cholesterol, LDL
cholesterol, diastolic arterial pressure, and carotid intima-
media thickness in the intervention group. For the first time,
the impact of a playful intervention program on the progress
of atherosclerosis was demonstrated.
One of the strengths of this study was the fact that the
sample was paired by gender and age, mitigating possible
influences of these variables on the anthropometric and
metabolic parameters during the study period.
Physical activities in this program had a recreational
nature, emphasizing that this type of activity, together with
nutritional guidance, also provides positive effects on obese
Table 1 – Anthropometric and metabolic characteristics of before and after the intervention groups – PICCOLI study,
Florianópolis, SC, Brazil, 2010.
VariablesIntervention group Control group
Before (n = 16)After (n = 16) Before (n = 16) After (n = 16)
Average ± SDAverage ± SDpAverage ± SDAverage ± SDp
BMI (kg/m2)26.6 ± 3.7 25.5 ± 3.8 0.001* 28.4 ± 5.228.7 ± 5.2 0.078
WC (cm)87.6 ± 9.5 86.4 ± 10.00.060 90.7 ± 12.1 94.3 ± 12.00.001*
TC (mg/dL)209.3 ± 49.2184.8 ± 41.1 0.001* 192.7 ± 34.5177.4 ± 24.7 0.042*
HDL-C (mg/dL) 58.6 ± 11.654.4 ± 14.0 0.375 60.5 ± 16.1 47.8 ± 18.7 0.012*
LDL-C (mg/dL) 130.9 ± 45.3112.7 ± 40.7 0.001* 113.6 ± 27.1107.8 ± 19.80.458
GL (mg/dL)85.9 ± 8.8 85.1 ± 8.10.74784.1 ± 8.1 87.9 ± 8.3 0.025*
SBP (mmHg)111.5 ± 10.9 105.7 ± 6.3 0.053114.4 ± 14.6118.1 ± 13.80.362
DBP (mmHg)70.3 ± 8.165.3 ± 7.50.010*73.8 ± 14.970.7 ± 5.40.375
BMI, body mass index; WC, waist circumference; TC, total cholesterol; HDL-C, HDL cholesterol, LDL-C, LDL cholesterol, GL, blood glucose; SBP,
systolic blood pressure; DBP, diastolic blood pressure.
* Statistically significant difference (paired t test).
REV ASSOC MED BRAS. 2013; 59(1):56-63
Table 2 – Results regarding the measurement of carotid artery, triglycerides, and C-reactive protein before and after the
intervention – PICCOLI Study, Florianópolis, SC, Brazil, 2010.
Intervention groupControl group
Before (n = 16) After (n = 16)pBefore (n = 16) After (n = 16)p
Median [IQR] Median [IQR]Median [IQR]Median [IQR]
Average IMT (mm) 0.43 [0.40-0.45]0.41 [0.40-0.43] 0.003*0.43 [0.39-0.47]0.44 [0.41-0.50] 0.012*
Maximum IMT (mm)0.56 [0.52-0.64] 0.52 [0.52-0.56]0.002* 0.54 [0.48-0.60]0.56 [0.52-0.66]0.024*
TG (mg/dL)93.0 [77.5-111.9]82.5 [68.0-101.0] 0.244 85.5 [64.7-118.0] 94.0 [62.2-134.7] 0.532
CRP (mg/L) 1.8 [1.4-5.0] 0.8 [0.7-2.7]0.1242.2 [0.9-6.1] 7.0 [1.6-9.0] 0.016*
IQR, interquartile ranges; IMT, intima-media thickness; TG, triglycerides; CRP, Ultra-sensitive C-reactive protein.
* Statistically significant difference (Wilcoxon test).
children, in addition to regular treatment (monitoring,
treatment, and traditional medical counseling). Such
results may suggest that the magnitude of the impact of the
program was similar to that of other structured physical
exercise programs with12 or without24 nutritional guidance.
A study that used intervention with similar
characteristics as those of the present study – 12 weeks
of physical exercises with recreational activities and
nutritional guidance – also showed positive effects on
the components of metabolic syndrome and on insulin
resistance, with significant reductions in the BMI,
leptin levels, systolic blood pressure, total cholesterol,
triglycerides, and glucose levels in obese children.13
Another study involving a low-calorie diet, and aerobic
physical activity and recreational games for obese children,
showed an increase in HDL-cholesterol, regardless of
the baseline value, when compared to low-calorie diet
only.25 This study demonstrated that diet alone or diet
combined with aerobic exercises reduces total cholesterol
and LDL cholesterol, when these show high levels.25 Other
results suggest that pediatric patients with metabolic
syndrome show great improvements with physical
exercises and nutritional guidance, demonstrating a
significant improvement in the lipid profile after a short
intervention period (two weeks, with daily physical
exercises).11,26 In these programs for obese children with
metabolic syndrome, gymnastics and games, in addition
to nutritional guidance, resulted in significant reductions
in the body mass, BMI, total cholesterol, blood pressure,
and triglycerides.11,26 Reductions in waist circumference,
HDL cholesterol,11 and LDL cholesterol26 were also found.
The results found in the present study demonstrate
that, although the intervention period was relatively
short to promote major changes in the BMI, important
improvements in the metabolic profile after the
intervention were verified. This appears to be especially
important to children’s health, as the intensity, extent,
and prevalence of atherosclerosis appear to be related to
the occurrence and severity of cardiovascular risk factors
typically described in adults;8 the most influential factor in
the acceleration of this process is dyslipidemia, especially
when total cholesterol, LDL-cholesterol, and triglycerides
levels are high, and HDL-cholesterol levels are reduced.27
The benefits in the reduction of anthropometric parameters
(BMI and, although not significant, waist circumference),
should also be emphasized, given the severity of obesity,
by the associated comorbidities.3,4
Regression of carotid intima-media thickness was
significant in the intervention group, which may suggest
reduction in the risk of events related to atherosclerosis
in the medium and long terms, if healthy habits are
maintained. Such reduction reinforces the findings of a
previous study28 that demonstrated an improvement in
intima-media thickness within six months of physical
exercises under supervision, suggesting a significant
reversibility of atherosclerosis progression in childhood,
when following a physical exercise program combined
with nutrition counseling. Another study also evidenced
that obesity related to vascular dysfunction was partially
reversible with diet alone or diet combined with physical
exercises during six weeks, with substantial progress in
those that maintained diet and physical exercises for 12
months, showing lower carotid artery thickness.29 However,
the results found in this study, although significant, may
also be attributed to technical issues, as the device used to
evaluate the carotid artery thickness is very sensitive and
REV ASSOC MED BRAS. 2013; 59(1):56-63
capable of detecting subtle changes in less time, as it has
a very high resolution. New studies are required to identify
the clinical meaning of these changes in the medium
and long terms. In any case, ultrasound measurement
of carotid intima-media thickness has been emerging as
a test with great potential for noninvasive evaluation of
atherosclerosis, evidencing the association between carotid
artery thickness and incidence of cerebrovascular and
In this study, no improvements regarding waist
circumference, HDL cholesterol, triglycerides levels, fasting
glucose, C-reactive protein, and systolic blood pressure
were observed at the end of the program. Other studies
also did not find effects on triglycerides25 and glucose12
levels after the intervention, confirming the present
findings. However, there are studies that have found
improvements in these variables with a program similar
to the present study’s.13 It is possible that these differences
may be attributed to the amount and intensity of physical
exercises, total duration of the program, caloric restriction,
initial body fat distribution, and initial metabolic profile.
One of the limitations of this study was the lack of an
effective control of the groups’ daily eating habits, which
may have influenced the non-significant effects, after the
program, on levels of triglycerides, blood glucose, and
HDL cholesterol. Additionally, different parameters may
require different levels of physical exercises, which may
also have influenced the variation in the results. Studies
with a higher number of children may bring important
contributions to the behavior of such variables.
It is important to highlight that the children proved to be
very receptive to most of the proposed activities, especially
regarding water activities. Although it is a physical
exercise program with recreational activities, children
remained within the target zone during the sessions, for
approximately 40 minutes, with individual variations
according to polar data; circuits and trampoline activities
were the exercises that maintained the children most of the
time within the recommended target zone. The importance
of nutrition meetings developed throughout the program in
order to encourage changes in the children’s eating habits
The use of medications during the program was
another limitation, which may have influenced the results
obtained. However, initial data about the metabolic
and anthropometric profile was similar between the
groups, regardless of the drug used, and no child in the
group started or ceased medication after the start of the
monitoring. Adiposity was determined only through the
BMI result, which does not necessarily measure adiposity.
The sample loss (27.3%) during the intervention was not
expected. Losses were higher than those of other studies
carried out with obese young people.12,26 Some factors
may have contributed to such losses, e.g., difficulty of
transportation, since many children depended on public
transportation and the project did not have the resources to
control such difficulty; the presence of a person responsible
for the child to conduct him/her to the intervention site
was required, which conflicted with work duties.
The physical exercise and nutritional guidance program,
in addition to the regular clinical treatment, was effective
in reducing BMI, total cholesterol, LDL cholesterol, diastolic
arterial pressure, and carotid intima-media thickness (an
indirect and early sign of atherosclerosis). Considering the
implications of obesity on children’s health, such findings
are important, warning of the importance of preventing
such cardiovascular risk factors during childhood.
Professor PhD. José Cazuza de Farias Junior, professor MSc.
Ileana Kazapi, professor Wagner Luiz Testa, nurse Maria
Cristina de Almeida Fernandes, Joy Bergamnn Soares,
Adriana Cassia Pirassol, Rogéria Perin, Tatiane Flores, Juliana
Carlos e Souza, and Pedro Albuquerque.
Conflict of interest
All authors declare to have no conflict of interest.
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