M. Cauderay1, F. Cachat2
1 USCADE Foundation, Pully, Switzerland
2 University Hospital, Department of Pediatrics, Division of Pediatric Nephrology, Bern, Switzerland
Physical activity is recognized as a basic component of the management of the obese child, but it is not clear which kind of intervention is the most efficient. The aim of this study is to evaluate the effect of prescribed exercise training in obese children. We reviewed 19 studies, 10 RCT and 9 observational studies, published in the last 5 years. In the majority of these studies obese children were treated as ambulatory patient, in tertiary centers. Only 2 studies described a community based program. In half of the studies, drop-out was not reported and the rate of attendance was rarely described. On the other hand, the content of each session was well described, but exercise training intensity was below international recommendations.
The analysis and interpretation of the current literature about exercise therapy in child obesity is difficult. The differences in program settings, in participant compliance and in measured outcomes, make the studies difficult to compare. Instead of focusing on intensity, program implementation should emphasize the special needs of obese children including their social background and the local network available.
L’activité physique est incontestablement l’un des piliers de la prise en charge des enfants obèses. Cependant, son efficacité demeure incertaine et la meilleure stratégie d’intervention reste à établir.
Le but de cette étude est d’évaluer l’effet des cours d’activité physique dans le traitement de l’obésité infantile. Nous avons revu la littérature spécifique de ces 5 dernières années. 19 études, 10 essais randomisés contrôlés et 9 études observationnelles, ont été retenues. La majorité des investigations ont été réalisées dans des centres tertiaires. Seules 2 études se sont intéressées à une approche communautaire. Dans la moitié de ces études, le nombre d’abandon n’était pas disponible. Le degré de participation était encore plus rarement rapporté. Si le contenu des cours était bien décrit, leur intensité était généralement en-dessous des recommandations internationales.
L’analyse et l’interprétation de la littérature récente, concernant l’effet thérapeutique de l’activité physique dans l’obésité infantile ne sont pas aisées. Les études sont difficilement comparables entre elles en raison du type de programme, de la compliance des enfants et de la mesure des résultats. Plutôt que de considérer l’intensité, la mise en place de programme d’activité physique devrait se centrer sur les besoins spécifiques des enfants obèses, de leur environnement socio-économique et des possibilités locales.
Despite numerous guidelines and recommendations, daily management of the obese child remains a difficult task for treating physicians [1,2]. Physical activity is now admitted as being an integral element of pediatric obesity treatment, but it is not clear which intervention is the most efficient [3,4]. Physical activity is an extremely complex behavior that requires active involvement of the child and his family as well. It is influenced by personal, family and environmental factors  and each of these elements can be a potential barrier in preventing active participation of the child, therefore compromising a successful implementation of a program. These limitations are obvious for moderate-to-vigorous physical activity which is usually recommended for treating obese children . In Europe, the reported prevalence of children spending more than 60 minutes a day in moderate-to-vigorous physical activity is very low. Only a quarter of European children did achieve this requirement [7,8,9]. To further complicate the assessment of physical activity in the management of pediatric obesity, several methodological biases make careful analysis and comparison difficult: the study designs, the assessment tools of physical activity and the goals of physical activity, (weight loss or prevention of weight gain) all differ in published reports [10,11]. The aims of this narrative study are therefore to evaluate the most recent studies that describe exercise training interventions and to find out which elements are more relevant in reducing weight in obese children and could be implemented in such programs.
Material and method
We searched Medline (via Pubmed) using the following keywords (free text): “exercise training” OR “exercise therapy” OR “physical activity” OR “physical fitness” OR “oxygen consumption” in combination with “obese children” OR “obese adolescents”. There was no language limits. Age was limited to subjects under 18 years of age. Publications prior to 2010 have already been extensively reviewed [12–16], we therefore limited our review to studies published during the last 5 years, i.e. from January 1, 2010 to January 31, 2015. Only studies that clearly described the physical intervention used and session content were recorded.
177 articles were found. After reading the title and the abstracts or the full texts, 19 articles met our criteria and were included [17–35]. The main characteristics of the 19 publications are summarized in table 1 and table 2. In 14 studies obese and overweight children were both enrolled. In 15 studies only obese or severely obese children were considered [18,19,21–22,26,28–29,33–35]. In 17 studies obesity and overweight were defined using the International Obesity Task Force criteria , whereas national standards  were used in 2 studies [24, 29]. Physical activity programs were performed mostly in tertiary centers except for 2 studies that reported the effectiveness of a physical activity program in the community [24,32]. In 4 studies, exercise training was provided during hospitalization in specialized centers, defined as an inpatient program [24,25,27,29]. The number of children enrolled was generally low, below 50. Only one study enrolled more than 100 children . All but 2 studies had a control group [31,33]. When reported, the drop-out rate varied between 20% to 50% [20–22,24,30,33–35]. The rate of attendance reflecting participants’ compliance to the program was detailed in 4 studies and varied from 87% to 94.5% (87%, 94.5%, 93%, 89% respectively) [20,22,30,31]. In about half the studies, exercise training alone was used [19,21–23,30–32,35]. In the remaining ones, dietary and exercise interventions were combined. Duration of the intervention greatly varied across studies, lasting from 3 to 12 months. 3 interventions only lasted less than 3 months [18,27,30]. Regarding the exercise prescription itself, the weekly time devoted was below 300 minutes, for programs longer than 3 months [17,19–26,28,29,31–35]. In 2 studies, exercise training time was greater than 300 min per week [18,27]. These more intense programs were provided as short interventions, i.e. less than 3 months. The content of sessions was well described in all studies and was supervised by a professional physical trainer. Most of the programs were based on aerobic endurance and provided a wide range of intensity levels, from 40% to 85% of maximal heart rate, corresponding to moderate-to-vigorous level [17–19,21–28,30,32–34]. 3 studies focused their intervention on higher exercise intensity or on interval training sets [20,31,35]. 3 other studies were obviously based on motor skills proficiency [25,31,33]. Outcomes were related to anthropometric or metabolic data rather than physical fitness results. Only 3 studies specifically assessed the effect of training on psychological parameters or psychosocial adjustment [20,29,30].
In this narrative review, we were able to carefully analyze the most important papers published over the last 5 years which describe the effectiveness of physical exercise in pediatric obesity programs. The variations in terms of duration of programs, settings, intensity levels and type of physical activity make comparison almost impossible. These differences make comparison between programs and evaluation of their results difficult and implementation potentially hazardous.
More specifically, we can make the following comments from a methodological point of view:
The duration and content of physical activity differed greatly from one study to another. In our review only short interventions achieved the recommended physical activity level. Most of the ambulatory programs, including moderate-to-vigorous intensity sessions, were still below the suggested physical activity levels [6,38,39,40], thereby questioning the effectiveness of these interventions [10,14]. To reach optimal level of physical activity, intensity can be increased and/or intermittent interval training can be incorporated into sessions; these options are closer to the spontaneous pattern of physical activity in childhood [41,42]. In general, high intensity training has been shown to bring greater enjoyment and to have good impact on physical fitness and anthropometric data [21,35,43,44].
As previously reported, few studies recorded the flow of participants, in particular the number of drop-outs. This poor reporting contrasts with the fact that many researchers indeed recognize the importance of long-term adherence to the program. Several authors emphasize the following aspects: to “encourage participation” , for the program to be “enjoyable” , for the need to be “designed for fun to increase adherence” [23,31] or to “experience success” . There are many factors that can improve participants’ adherence. Improving self-perceived physical ability is one of them and has been shown to be a good predictor of involvement in a future physical activity [31,45]. Social interaction during group sessions has also been highlighted as a determining factor in developing of a positive perception of physical activity. It decreases the feeling of “being insecure about appearance” and “not being good at” which are major barriers towards physical activity. Better self-motivation is likely to increase compliance to the programs [46,47]. In the same vein, socio-economic and family limitations can also impact the participation of the child and his family. Children from low backgrounds have been shown to have less access to sport, which explain more increase in difficulty to complete a program. Families with low incomes have more difficulty in affording a program and are more prone to drop out when enrolled [20,48,49]. Close interaction with the parents throughout the program to take into account their expectations increases adherence [50,51].
Beyond the mere physical activity, motor skills are also matter of interest in several studies [29,31]. Locomotion, object control and stability, representation of the fundamental movement skills, were shown to be good predictors of time spent daily in action. In healthy normal weight children, object control proficiency is well correlated to the time spent in moderate-to-vigorous physical activity time spent when they became adolescent . Fundamental movement skills enable specialized sequences required to practice organized and non-organized physical activity . Children with better motor skills have a better perception of their athletic competence and have more chance to be involved in sports during adolescence, increasing their level of physical activity [52,54,55]. On the other hand, children with developmental coordination disorder are prone to be obese although the causal effect of developmental coordination disorder and obesity remains a matter of discussion [56,57]. Overall, obese children show lower fundamental movement skills than their normal-weight peers [58,59,60]. In prospective studies, the diminished motor competence in obese children did not improve over time, contrary to their non-obese peers . In opposition to gross motor competence, fine motor skills in obese children do not differ from their counterparts . These data support the hypothesis that motor skills impairment in obese children bears a negative impact on self-perceived physical competence and could worsen their low participation in physical activities, thereby initiating a vicious circle.
Excellent reviews on physical activity to treat pediatric obesity, including a Cochrane reviews were recently published . We therefore limited our study to the last 5 years. Given the nature of our research, this cannot be considered as a systemic review. After carefully reading the conclusion of the Cochrane review  the inclusion of papers published prior to 2010 would not significantly alter our conclusions.
The analysis and interpretation of the current literature about exercise therapy to treat obesity show major differences between studies. In- or out-patient program settings, length of the program or of the sessions, compliance and measured outcomes make the studies difficult to compare and their success difficult to evaluate at the present time. To improve participants’ compliance and finally program success, the special needs of the obese child, including his social background and the available local network, should be taken into account.
Acknowledgments, conflict of interest
The authors have no conflict of interest to declare. The authors thank Mrs Fretz-Tongue for her kind help for translation.
Dr Michel Cauderay
av. de Chantemerle 10
- Fulton J, Garg M, Galuska D, Rattay K, Caspersen C. Public health and clinical recommendations for physical activity and physical fitness. Special focus on overweight youth. Sports Med. 2004;34(9):581-5699.
- Spear B, Barlow S, Ervin Ch, Ludwig D, Saelens B, Taveras E. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120 suppl 4:S255-S267.
- Holm JC, Gamborg M, Bille D, Gronbaek H, Ward L, Faerk J, Chronic treatment of obese children and adolescents. Int J Pediatr Obes. 2011;6:188-196.
- Kirschenbaum D, Gierut K. Treatment of childhood and adolescence obesity: an integrative review of recent recommendations from five expert groups. J Consult Clin Psychol. 2013;81(2):347-360.
- Lawman H, Wilson D. Associations of social and environmental supports with sedentary behavior, light and moderate-to-vigorous physical activity in obese underserved adolescents. Int J Behav Nutr Phys Act. 2014;11:92-101.
- ’Donovan G, Blazevich A, Boreham C, Cooper A, Mutrie N, Reilly J, Saxton J, Stamtakis E. The ABC pf physical activity for health: a consensus statement from the British association of sports and exercise sciences. J Sports Sci. 2010; 28(6):573-591.
- Kovacs E, Siani A, Konstabel K, Hadijgeorgiou C, de Bourdeauhuij I, Ahrens W, Molnar D, on behalf of the IDEFICS study. Adherence to the obesity-related lifestyle intervention targets in the IDEFICS study. Int J Obes. 2014;38:S144-S151
- Laguna M, Ruiz J, Gallardo C, Garcia-Pastor T, Lara MT, Aznar S. Obesity and physical activity patterns in children and adolescents. J Paediatr Child Health. 2013;49:942-949.
- Kahlmeier S, Wijhoven T, Alpiger P, Schweizer Ch, Breda J, Martin B. National Physical activity recommendations: systemic overview and analysis of the situation in European countries. BMC Public Health. 2015;15:133-147
- Trinh A, Campell M, Ukoumunne O, Gerner B, Wake M. Physical activity and 3-year BMI change in overweight and obese children. Pediatrics. 2013;131:e470-e477.
- Wilks D, Sharp S, Ekelund U, Thompson S, Mander A, Turner R, Jebb S, Lindroos A. Objectively measured physical activity and Fat Mass in children: a bias-adjusted meta-analysis of prospective studies. PLoS One. 2011;6(2):e17205.
- Ho M, Garmett P, Baur L, Burrows T, Stewart L, Neve M, Collins C. Impact of dietary and exercise intervention on weight change and metabolic outcomes in obese children and adolescents. A systematic review and meta-analysis of randomized trials. JAMA Pediatr. 2013;167(8):759-768.
- Saavedra J, Escalante Y, Garcia-Hermoso A. Improvement of aerobic fitness in obese children: a meta-analysis. Int J Pediatr Obes. 2011;6:169-177
- Atlantis E, Barnes E, Fiatarone Singh M. Efficacy of exercise for treating overweight in children and adolescents: a systematic review. Int J Obesity. 2006;30:1027-1040.
- Garcia-Hermoso G, Saavedra J, Escalante Y, Sanchez-Lopez M, Martinez-Vizcaino V. Aerobic exercise reduce insulin resistance markers in obese youth: a meta-analysis of randomized controlled trials. Eur J Endocrinol. 2014;171:R163-R171.
- Cliff D, Okely A, Morgan P, Jones R, Steele J. The impact of child and adolescent obesity treatment intervention on physical activity: a systematic review. Obesity Reviews. 2010;11:516-530.
- Nemet D, Levi L, Pantanowitz M, Eliakim A. A combined nutritional-behavioral-physical activity intervention for treatment of childhood obesity- a 7-year summary. J Pediatr endocrinol Metab. 2014;27(5-6):445-451.
- Ben Ounis O, Ellouni M, Zouhal H, Makni E, Tabka Z. Effect of individualized exercise training combined with diet restriction on inflammatory markers and IGF-1/IGFBP-3 in obese children. Ann Nutr Metab. 2010;56:260-266.
- Zorba E, Cengiz T, Karacabey K. Exercise training improves body composition, blood lipid profile and serum insulin levels in obese children. J Sports Med Phys Fitness. 2011;51(4):664-669.
- Pescud M, Pettigrew S, McGuigan M, Newton R. Factors influencing overweight children’s commencement of and continuation in resistance training program. BMC Public Health. 2010;10:709-717.
- Racil G, Ben Ounis O, Hammouda O, Kallel A, Amri A. Effects of high vs. moderate exercise intensity during interval training on lipids and adiponectin levels in obese young females. Eur J Appl Physiol. 2013;11:2531-2540.
- Calcaterra V, Larizza D, Codrons E, De Silvestri A, Arpesella M, Vandoni M. Improved metabolic and cardiorespiratory fitness during recreational training program in obese children. J Pediatr Endocrinol Metab. 2012;26(3-4):271-276.
- Vanhelst J, Mikulovic J, Fardy P, Bui-Xuan G, Marchand F, Béghin L, Theunynck D. Effect of a multidisciplinary rehabilitation program on pediatric obesity: the CEMHaVi program. Int J Rehabil Res. 2011;34:110-114.
- Van der Baan-Slootweg O, Benninga M, Beelen A, Van der Palmen J, Van Aalderen W. Inpatient treatment of children and adolescents with severe obesity in the Netherlands a randomized clinical trial. JAMA Pediatr. 2014;168(9):807-814.
- D’hondt E, Gentier I, Deforche B, Tanghe A, De Bourdeaudhuij I. Weight loss and improved gross motor coordination in children as a result of multidisciplinary residential obesity treatment. Obesity. 2011; 10(10):1999-2005.
- Nemet D, Oren S, Pantanowitz M, Eliakim A.. Effects of a multidisciplinary childhood obesity treatment intervention and adipocytokines, inflammatory and growth mediators. Horm Res Paediatr. 2013;79:325-332.
- Roberts Ch, Izadpanah A, Angadi S, Barnard R. Effect of an intensive short-term diet and exercise intervention: comparison between normal-weight and obese children. Am J Physiol Regul Integr Comp Physiol. 2013;305:R552-R557.
- Ackel-D’Elia C, Carnier J, Bueno JR C, de Mello M, Dâmaso A. Effects of different physical exercises on leptin concentration in obese adolescents. In J Sports Med. 2014;35:164-171.
- Verloigne M, De Bourdeaudhuij I, Tanghe A, D’hondt E, Vansteenkiste M, Deforche B. Self-determined motivation towards physical activity in adolescents treated for obesity: an observational study. Int J Behav Nutr Phys Act. 2011;8:97-108.
- Wagener T, Fedele D, Mignogna M, Hester C, Gillaspy S. Psychological effects of dance-based group exergaming in obese adolescents. Pediatr Obes. 2012;7:e68-e74.
- Morano M, Colella D, Rutigliano I, Fiore P, Pottello-Mantovani M, Campanozzi A. Changes in actual and perceived physical abilities in clinically obese children: a 9-month multi-component intervention study. PLoS ONE. 2012;7(12):e50782.
- Park JH, Miyahita M, Kwon YC, Prak HT, NakamuraY, Park SK. A 12-week after school physical activity programme improves endothelial cell function in overweight and obese children: a randomized controlled study. BMC Pediatr. 2012;12:111-120.
- Steinberg N, Eliakim A, Pantanowitz M, Kohen-Raz R, Zeev A, Nemet D. The effect of a weight management program on postural balance in obese children. Eur J Pediatr. 2013;172:1619-1626.
- Prado D, Silva A, Trombetta L, Ribeiro M, Guazzelli I, Matos L, Santos M, Nicolau C, Negrao C, Villares S. Exercise training associated with diet improves heart rate recovery and cardiac autonomic nervous system activity in obese children. In J Sports Med. 2010;31:860-865.
- Corte de Araujo A, Roschel H, Picanço A. Leite do Prado M. Ferreira S. de Sa Pinto A. Gualano B. Similar health benefits of endurance and high-intensity interval training in obese children. PLoS One. 2012;7(8):e42747.doi:10.1371.
- Cole T, Bellizzi M, Flegal K, Dietz W. Establishing a standard definition for child overweight and obesity worldwide international survey. BMJ. 2000;320:12401243.
- Cole T, Roede M. Centiles of body mass index for Dutch children aged 0-20 years in 1980-a baseline to assess recent trends in obesity. Ann Hum Biol. 1999;26:303-308.
- Saris W, Blair S, Van Baak M, Eaton S, Davies P, Di Pietro L, Fogelholm M, Rissanen A, Schoeller D, Swinburn B, Tremblay A, Westertrep K, Wyatt H. How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st stock conference and consensus statement. Obesity Reviews. 2003;4:101-114.
- World health Organization. Global recommendations on physical activity for health. Geneva: World Health Organization, 2010.
- Martin B, Mäder U, Stamm H, Braun Ch, Farhländer P. Physical activity and health- what are the recommendations and where do we find the Swiss population? Schweiz Z Sportmed. 2009;57(2):37-43.
- Sgro M, McGuigan M, Pettigrew S, Newton R. The effect of duration of resistance interventions in children who are overweight or obese. J Strength Cond Res. 2009;23(4):1263-1270.
- Guet G, Gamelin FX, Mucci P, Thévenet D, Van Praagh E, Berthoin S. Continuous vs interval aerobic training in 8- to 11-year-old children. J Strength Cond Res. 2010;24(5):1381-1388.
- Bartlett J, Close G, McLaren D, Gregson W, Drust B, Morton J. High-intensity interval running is perceived to be more enjoyable than moderate-intensity continuous exercise: implications for exercise adherence. J Sports Sci. 2011;29(6):547-553.
- Lau P, Wong D, Ngo J, Laing Y, Kim C, Kim H. Effects of high intensity intermittent running exercise in overweight children. Eur J Sport Sci. 2015;15(2):182-190.
- Deforche B, Haerens L, De Bourdeaudhuij I. How to make overweight children exercise and follow the recommendations. Int J Pediatr Obes. 2011;6(S1):35-41.
- Deforche B, De Bourdeaudhuij I, Tanghe A. Attitude toward physical activity in normal-weight, overweight and obese adolescents. J Adol Health. 2006;38:560-568.
- Markland D, Ingledew D. The relationships between body mass and body image and relative autonomy for exercise among adolescent males and females. Psychol Sport Exerc. 2007;8:836-853.
- Davis A, Daldalian M, Mayfield C, Dean K, Black W, Sampilo M, Gonzalez-Mijares M, Suminiski R. Outcomes from an urban pediatric obesity program targeting minority youth: the healthy hawks program. Child Obes. 2013;9(6):492-499.
- Epstein L, Paluch R, Wrotniak B, Wifeley D, Finkelstein E. Cost-effectiveness of family-based group treatment for child and parental obesity. Child Obes. 2014;10(2):114-121.
- Skelton J, Goff D, Ip E, Beech B. Attrition in a multidisciplinary pediatric weight management clinic. Child Obes. 2011;7(3):185-193.
- Giannisi F, Pervanidou P, Michalaki E, Papanicolaou K, Chrousos G, Yannakoulia M. Parental readiness to implement life-style behavior changes in relation to children’s excess weight. J Paediatr Child Health. 2014;50:476-481.
- Barnett L, Van Beurden E, Morgan PH, Brooks L, Beard J. Childhood motor skill proficiency as a predictor of adolescent physical activity. J Adolesc Health. 2009;44:252-259.
- Lubans D. Morgan Ph. Cliff D. Barnett L. Okely D. Fundamental movement skills in children and adolescents. Review of associated health benefits. Sports Med 40(12):1019-1035,2010.
- Vandorpe B, Vandenriessche J, Vaeyens R, Pion J, Matthys S, Lefevre J, Philippaerts R. Lenoir M. Relationship between sports participation and the level of motor coordination in childhood: a longitudinal approach. J Sci Med Sport. 2012;15:220-225.
- Piek J, Baynam G, Barrett N. The relationship between fine and gross motor ability, self-perception and self-worth in children and adolescents. Hum Mov Sci. 2005;25:65-75.
- Hendrix C, Prins M, Dekkers H. Developmental coordination disorder and overweight and obesity in children: a systematic review. Obesity. 2014;15:408-423.
- Lopes V. Stodden D. Bianchi M. Maia J. Rodrigues L. Correlation between BMI and motor coordination in children. J Sci Med Sport 15: 38-43,2012.
- Okely A, Booth M, Chey T. Relationships between body composition and fundamental movements skills among children and adolescents. Res Q Exerc Sport. 2004;75(3):238-247.
- Nunez-Gaunaurd A, Moore J, Roach K, Miller T, Kirk-Sanchez N. Motor proficiency, strength, endurance and physical activity among middle school children who are healthy, overweight and obese. Pediatr phys Ther. 2013;25:130-138.
- Cliff D, Okely A, Morgan PH, Jones R, Steele J, Baur L. Proficiency deficiency: mastery of fundamental kills and skill components in overweight and obese children. Obesity. 2012;20:1024-1033.
- D’Hondt E, Deforche B, Gentier I, De Bourdeaudhuij I, Vaeyens R, Philippaerts R, Lenoir M. A longitudinal analysis of gross motor coordination in overweight and obese children versus normal-weight peers. Int J Obes. 2013;37:61-67.
- Gentier I, D’Hondt E, Schultz S, Deforche B, Augustijn M, Hoorne S, Verlaecke K, De Bourdeaudhuij I, Lenoir M. Fine and gross motor skills differ between healthy-weight and obese children. Res Dev Disabil. 2013;34:4043-4051
- Luttikhuis O, Baur L, Jansen H, Shrewsbury V, O’Malley C, Stolk R, Summerbell C. Intervention for treating obesity in children. Cochrane Database Syst Rev. 2009;(1):CDO1872.