Physical Activity As Treatment For Childhood Overweight Conditions - Melinda Sothern

Physical Activity as
Treatment for Childhood

Overweight Conditions
Melinda S. Sothern, PhD

Professor and Director
Health Promotion and Pediatric
Obesity Research
School of Public Health
Louisiana State University
Health Sciences Center
Pennington Biomedical Research
Center
Email: msothe@lsuhsc.edu
Melinda Sothern, LSUHSC School of Public Health Jump to first page
Melinda Sothern, LSUHSC School of Public Health
Overweight Children
and Physical Activity
Recent research indicates
that, especially in girls,
dancing promotes an
improvement of weight
status and may be useful in
the prevention of pediatric
obesity. Robinson, et al, 2003 (GEMS); Engels, et al, JADA, 2005;
Ildiko, et al, J Physiol Anthropol, 2007 (Folk); Tak, et al, Taehan Kanho Hakho Chi, 2007 (Hip-Hop)
Jump to first page
Motivating Overweight
Children to Increase
Physical Activity
Do a
Little
Dance!
Jump to first page
When most of today’s
parents were kids:
There were no
computers, video
games, cable TV
and few fast food
restaurants.

Jump to first page
Today U.S. Children
watch TV an average
of 20 to 30 hours per
week.
They view 40,000
ads per year.
Advertising
exposure is related
to childhood obesity,
poor nutrition,
cigarette and alcohol
abuse.
Melinda Sothern, LSUHSC School of Public Health Pediatrics, 2006; Caroli,
Jump toet
firstal, 2004
page
When most of today’s
parents were kids:
Most kids spent
their days
riding bikes,
climbing trees,
and playing
tag.
Today Melinda Sothern, LSUHSC School of Public Health
Children are 6 times more likely play

a video game than to ride a bike.
Only 47% of children report riding bikes

at least 6 times a year—down 31%
since 1995. Bike sales fell by 21%
in the past 5 years.
Only 6% of children report playing

baseball on their own. Swimming, fishing
and touch football are down 1/3 since
1995.
Jump to
CDC/Kaiser Foundation. 2005; NSGA; Bicycle Industry first page
News, 2005
Young children
will engage in
various types of
physical activity
if provided with
an environment
that promotes
free play.
DiNubile, 1993 Jump to first page

Large motor skills
(running, skipping,
hopping, the
―butterfly‖) are
associated with better
cognitive functioning
(and reading ability)
later in life.
This spontaneous
activity declines 50%
between the ages of 6-
16 years.
Kalish, 2007; Hillman, 2006; USDA, 1998 Jump to first page

Let the Children Play!

Vigorous,
intermittent
physical activity
is shown to
reduce
components of
the metabolic
syndrome in
pre-pubertal
children.
Barre, et al, 2006; Owens, 2006; Barbeau, et al, 2007; Yu, et al,, 2005; Kahle, 1996;
Shaibi, et al, 2006; Nassis, 2005 Jump to first page
Evidence-based Recommendations for
Physical Activity in School-Age Youth
School-age youth should participate daily
in 60 minutes or more of moderate to
vigorous physical activity that is:
 Developmentally
appropriate
 Enjoyable
 Involves a variety
of activities
Strong, Malina, Blimkie, et al, J Pediatrics, 2005; U.S.
Jump2008
to first Guidelines
page
Evidence-based Recommendations for Physical
Activity in School-Age Youth – Type
 Pre-school Years:
General movement activities (jumping,
throwing, running, climbing)
 Pre-pubertal (6-9 years):
More specialized and complex movements,
anaerobic (tag, games, recreational sports)
 Puberty (10-14 years):
Organized sports, skill development
 Adolescence (15-18 years)
More structured health and fitness activities,
Strong, Malina, Blimkie, et al,
refinement of skills J Pediatrics, 2005;2008 U.toS.firstguidelines
Jump page
Activity in School-Age Youth
 Intensity
5 to 8 METs (moderate to vigorous) is
need to derive most health benefits,
such as active outdoor play, brisk
walking, cycling.
 Duration
A total of 60 minutes per day
Cumulative, not necessarily sustained
 Frequency
Daily
Strong, Malina, Blimkie, et al, J Pediatrics, 2005; 2008 U.S.
Jump to guidelines
first page
How can I include
physical activity
into my
treatment plan?

Jump to first page
American Heart Association

Childhood Obesity Summit
 The complex and multiple factors causing
pediatric obesity warrant a multi-
disciplinary, collaborative approach:
 Engage professionals across multiple

disciplines
 National effort including research, health,
advocacy, education, media, consumer
advertising.
Daniels SR, et al. American Heart Association Childhood Obesity Research

Summit: Executive Summary. Circulation (2009) 119: 2114-2123.Jump to first page
Prevention and Treatment of
Overweight Conditions in Childhood
Pediatrician
Behavioral Nutrition
Family Education
Counseling
Exercise and
physical activity
Jump to first page
Physical Activity as Treatment
for Overweight Children:
Learning Objectives
 Identify
appropriate and
reliable physical
activity
assessment tools
 Assess and
evaluate physical
activity level
Jump to first page
Overweight Children
Baseline Assessment
 Body composition
 Skin folds
 Bioelectrical impedance
 Dual Energy X-ray Absorptiometry
 Dietary history
 Psychological measures
 Self esteem
 Depression
 Self-efficacy
 Physical activity
rating
Jump to first page
Physical Activity Rating

 Accelerometry
 Intensity-weighted minutes of physical activity
 Records acceleration/deceleration of movement
 Objective measure that provides activity counts and
intensity.
 Heart Rate Monitoring
 Uses heart rate values to determine amount and
intensity of physical activity
 Self Report Questionnaires
 Godin Leisure Time, 7-day recall, SAPAC
 Direct Observation
 SOFIT, SOPLAY, SOPARK Jump to first page
Godin Leisure-Time Exercise Questionnaire

a) Strenuous Exercise (>15 min.) Times per Week
(Heart Beats Rapidly: 9 METS)
(i.e. running, jogging, hockey….) ______
b) Moderate Exercise (>15 min.)

(Not Exhausting: 5 METS)
(i.e. fast walking, baseball, easy bicycling….) ______
c) Mild Exercise (>15 min.)

(Minimal Effort: 3 METS)
(i.e. golf, easy walking, bowling….) ______
In a 7- day period how often do you engage in any regular
activity that works up a sweat?
Often Sometimes Never/rarely
Godin & Shephard, 1985 Jump to first page
Physical Activity Risk Questionnaire

First, let’s rate your child’s physical activity. Circle the
number that best describes your child (circle only 1 number):
1. He sits most of the time….likes to bowl, play billiards, go
fishing, do puzzles, … But he likes television, video and
computer games more.
4. She plays on a sports team, dances, or indoor physical
activity 2-3/week… He likes to run. He spends at least 2-
3 hours on weekend days practicing…
7. He plays chase, tag, basketball… or some other indoor or
outdoor game every day. Or he is on 2 or more sports
dance, gymnastics… team that practices every day….. He
practices or plays all day on Saturday or Sunday.
List the numeral you circled above: ________
Sothern, von Almen and Schumacher, Trim Kids (Harper first page 2001)
Resource,
Jump to
Overweight Children
Baseline Assessment
 Exercise tolerance
 Graded treadmill test
 Indirect calorimetry
 Heart rate and blood pressure
 Field fitness test
 Shuttle run
 Walk test
 Strength and flexibility
 80% maximum test
 Flex test
Metabolic Testing
 Maximal Oxygen Uptake (VO2max)
 Graded treadmill test
 Indirect calorimetry
 Heart rate and blood pressure
 Resting Metabolic Rate (RMR or REE)
 Indirect calorimetry hood system
 Respiratory Quotient (RQ or RER)
 Ratio of oxygen to carbon dioxide
 Indicates fuel source (oxidation)
 Total Energy Expenditure
 Stable Isotopes (Doubly labeled water) Jump to first page
Physical Activity as
Treatment for Overweight
Children:
Learning Objectives
 Identify physiologic
and metabolic
factors that limit
physical activity

Jump to first page
Physical Activity and
Metabolism
 The impact of physical activity on
metabolism is dependent on the type,
intensity and volume of activity pursued
by the individual.
 It is also dependent on the genetic

potential, gender and age, health and
current training status of the individual.
Jump to first page
Individual Response
to Physical Activity
Genetic Potential: is complex and
determined by many factors such as:
 Mitochondria size and number
 Muscle fiber type
Age and Gender
Health and Medical History
Current Training Status
 Sedentary
 Trained (specificity)
Classification of Muscle Fiber Types
Characteristic Slow-twitch Fast-Twitch(a) Fast-Twitch(b)

Type I Type IIa Type IIb
Aerobic capacity High Moderate Low
Anaerobic capacity Low High Highest
Oxidation High Moderate Low
Glycolysis Low High Highest
Force/size Low High Highest

03 NOV 09
Fatigue time Low High Highest

Melinda Sothern, LSUHSC School of Public Health Wilmore & Costill, 1994;
Jump toSothern,
first page 2001
Acute Response of
Physical Activity
Metabolism is increased:
during the actual physical activity
immediately after the physical activity
for hours following physical activity
 The prolonged impact of physical activity

is dependent upon:
the training status of the individual
the intensity of the exercise
the duration of the exercise
Excess Post-Exercise Oxygen
Consumption (EPOC)
O2 requirement
O2 deficit
EPOC
Steady-state O2
Resting O2 consumption
consumption
Start End End

exercise exercise recovery
Melinda Sothern, LSUHSC School of Public Health Wilmore & Costill,
Jump to first page 1994
Chronic Response of Physical Activity
Long-term exercise training may:

increase fat free mass and reduce
fat mass
improve oxidative capacity
increase resting metabolism
increase fat oxidation.
improve insulin sensitivity
Nassis, et al, Metabolism. 2005; Carrel, Arch Pediatr Adolesc Med. 2005 ; Dao, et al, Int’l J Ob, 2004
Carter, et al, Am J Physiol End Met, 2001; Kanaley, et al, Eur J Appl Physiol, 2001; Hurley & Hagberg,
Ex Sp Sci Rev, 1998; Ballor, et al, Int J. Obes, 1991; Horowitz, Ex Sport Sci Rev, 2001;
Haddock, Wilkin, 2006; Hunter, et al, 2006; Talanian, et al, 2007; Stiegler & Cunliffe, 2006;
Bell, J Clin Endoc & Met, 2007; Barbeau, et al, Obesity, 2001; Sothern, et al, J Invest
JumpMed,
to first1999,
page 2000
Aerobic Exercise
Improves body composition
Improves the oxygen transport
system
Improves endocrine function
Reduces low density and
increases high density blood
lipoproteins
Retards the catabolic process
associated with chronic heart failure
Schulze, et al Int J Cardiol, 2002; Sothern, Eur J of Ped, 1999; Wilmore & Costill, 1994;
Belanger, Boulay, 2005; Ventura-Clipier, et al, 2007
Jump to first page
Physical Activity and Fat
Oxidation
Endurance trained muscle stores more

glycogen and fat than untrained muscle.
Oxidative enzyme activity increases

Free fatty acid levels increase
Increased use of fat as an energy source
Sparing of muscle and liver glycogen
Lactate threshold increases reflecting an
improved ability to perform exercise aerobically at
higher intensities .
Byrne & Wilmore, Int J Sport Nutr Ex Met, 2001; Hurley & Hagberg, Ex & Sp Sci Rev., 1998;
Talanian, et al, 2007; Tonkonogi, et al, 2000; Kelley, D., 1999
Jump to first page
Oxygen Uptake in Trained and
Untrained individuals
70 VO2 Max
60
50
O2 40 Trained
mL/kg/ 30 Untrained
min
20 VO2 Max
10
0
Baseline 2 4 8 12
Baldwin, et al, Med Sci Spor Ex, 1999; Wilmore
Jump to& Costill,
first page 1994
Move it or Lose It
The effect of physical activity is
reversed if training ceases:
Protein synthesis  within 6 hrs.
Strength  3-4% per day.
Area and percentage of slow twitch fibers
 as muscles atrophy
Muscle endurance performance and
oxidative enzyme activity  after 2 weeks.
Respiratory quotient (RQ)
Muscle glycogen  40% after 4 weeks
Mujika & Padilla, Med Sci Spo Ex, 2000; Wilmore
Jump to& Costill,
first page 1994
Effect of Detraining on
Metabolism
Weeks
0 2 4 6
0
10
20 Maximal Oxygen
30 Uptake
% 40 Succinate
dehydrogenase *
decrease 50 Cytochrome
60 oxidase *
70 Muscle glycogen
80
90
100
* Oxidative Enzymes Wilmore
Jump to& Costill,
first page 1994
Physical Activity
Training and Youth
Do children
respond to physical
activity like adults?
Is physical activity
more difficult if the
child is overweight?
Jump to first page
Children and
Sedentary Behaviors
Physical Exercise
Activity Tolerance
Body
Snacking Mass
TV watching Index
Robinson, 1999; Sothern, 2001; Salbe,

Jump et al, 2002
to first page
VO2 L/min in Overweight
Adults and Children
3
2.5
2
VO2 Adults
1.5
Children
1
0.5
0
Baseline 2.5 mph 3.0 mph 3.5 mph Max
Jump top<0.05
Van Vrancken, Sothern, 1999; Two group repeated measures ANOVA; first page at Max
Overweight Youth Compared to Normal
Weight Youth (Mean Age: 12.4 yrs [Sothern
and colleagues, 1992-2007])
Parameter N Mean ± SD Normal Range
or Range
Percent Fat 24 43.1 ± 27.1 <30
Cholesterol 50 170.8 ± 29.3 <170
LDL 31 123.5 ± 25.7 <110
VO2Max 22 19.8 ± 4.4 45-53
Asthma 150 10.9 - 31.6% 10.5%
Liver Fat 9 0.049±0.04 0.022±0.02
Low Birth Wt. 177 3.4 - 29.6% <10%
High Birth Wt. 177 7.4 - 18.6% <10%
Jump to first page
Certified
Astronaut Hero
enrolled in the
SILLY study
Research sponsored by: NICHD Jump to first page

Exercise Tolerance in Children with Increasing

Overweight Levels
2.5
45
40
2
35
30
1.5
25
VO2 VO2 20
1
L/min mL/kg/ 15
min
10
0.5
5
0 0
Baseline 2.5 mph 3.0 mph 3.5 mph Max Baseline 2.5 mph 3.0 mph 3.5 mph Max
Severe (>99th% BMI) Overweight (>95th%BMI)

At Risk (>85th% BMI) Healthy (50-85th% BMI)
Sothern, et al, 1999 Four group repeated measures
JumpANOVA;
to first page p <0.03
Heart Rate during Walking in Children

with Increasing Overweight Levels
Healthy Weight
<85th BMI
37.8% of Max HR
Severe At Risk
>99th BMI
Walking 3.5 mph >85<95th BMI
85.3% of MaxHR 47.8% of MaxHR
Overweight
>95<99th
65.4% of MaxHR
Sothern, et al, 1999 Jump to first page
Is physical activity more difficult
if the child is overweight?
A group of 43 eight-year-olds
with an average weight of 40
kg took twice as long as average-
weight kids to get out of a lounge
chair. Some even needed
assistance.
"They have flatter feet, collapsed arches,".

"We think they are just more uncomfortable
all the time." (Professor Steele)
Steele, et al, 2006, Int’l J of Ped Obesity
Jump to first page
Jump to first page

Fig 1. Attainment of criteria for maximal cycle ergometry test
Norman, A.-C. et al. Pediatrics 2005;115:e690-e696

Jump to first page
Copyright ©2005 American Academy of Pediatrics
Excess Fat and Exercise Performance

Fatness and excess body weight do not necessarily imply a
reduced ability to maximally consume oxygen, but excess
fatness does have a detrimental effect on sub-maximal
aerobic capacity
Exercise prescriptions for overweight adolescents should
account for the limited exercise tolerance imposed by excess
body mass.
Low intensity training may counteract the decline in fat
oxidation from calorie reduction and improve insulin
sensitivity.
Prescriptions should focus on activities that keep demands
below lactate threshold so that exercise can be sustained.
Goran, Int‟l J Ob, 2000; Norman, Pediatrics 2005; Brandou, Diabetes Metabolism , 2005;
Nassis, Metabolism, 2005; Drinkard, Med Sci Sports Exer,Jump
2007
to first page
Overweight Children and
Sedentary Behaviors
Cardiopulmonary Physical
Function Activity
Body
Snacking
Mass
TV watching
Index
Sothern, 2001; Salbe, 2002

How can I get my
patient to reduce
TV and computer
game time?

Jump to first page
Reducing Sedentary Behavior versus
Increasing Physical Activity
Epstein et al., Arch. Pediatr. Adolesc. Med. 2000
Increase After-School Exercise or Decrease Sedentary Activity

Time Post Treatment
-10
-12 6 Months 12 Months 24 Months
-14
Weight Loss (%)
-16
-18
-20
-22 Exercise
-24 Sedentary
-26
-28
Jump to first page
Strategies to Decrease Sedentary
Behavior Inside the Home
 30-minute rule
 After 30 minutes of computer or written
work take a 3-5 minute break
 Allow active play before homework.
 Re-arrange the family or living room to
provide areas for movement.
 Turn on the stereo, not the TV.
 Interactive computer games
Sothern et al, Trim Kids, Harper Collins, 2001;
Jump to first page
Handbook of Pediatric Obesity: Clinical Management, 2006
30 Minute Rule
Research indicates that
after 30 minutes of mental
work the ability to
concentrate begins to
decline.
Sitting burns only 33-50
calories per hour.
Jump to first page
Music is a Motivational
Tool for Physical Activity
 The motivational qualities of music are
heightened when the music is delivered at a
higher volume.
 Females reported the importance of music
more highly than males.
 Music facilitates performance on
cardiovascular equipment more so than on
any other equipment.
 There is an effect of music compared to
age:
- Older adults (36-45 years) preferred non-
current music,
- Younger age groups (16-26) preferred
current music and dance music
Priest, et al, 2004
Jump to first page
Classy Moves – Exercise Breaks
 Rocky (martial arts/boxing moves)
 Raise the Roof (overhead press)
 Off the Wall (wall push-ups)
 Hot Seat (chair squats)
 Do the Swim
 Music break (dance to one song)
 Flex at Your Desk
 Stand like a tree and balance
 Reward positive behavior with indoor
or outdoor play periods Jump to first page
 Rocky (martial arts/boxing moves)
 Raise the Roof (overhead press)
 Off the Wall (wall push-ups)
 Hot Seat (chair squats)
 Do the Swim
 Reward positive behavior with indoor
or outdoor play periods
 Do the Swim
―We can dance if we want to…as
long as there is music, you’re never
gonna lose it…” (Men Without Hats)

 Reward positive behavior with indoor or
outdoor play periods
“ Dancing with myself, I’ll be dancing

with myself……If I had a chance, I’d
ask the world to dance….. (Billy Idol)

 Reward positive behavior with indoor or
outdoor play periods
Exercise Breaks and Improved
Weight and Metabolic Profiles
 Integrating daily 10-minute exercise breaks during
paid work time over one year in 335 adults
reduced waist circumference by 1.6 m (p<0.009)
in all, BMI (p<0.03) in males and DBP in females
(p<0.42 [Lara, et al, Prev Chronic Dis, 2008])
 Increased moderate-to-vigorous intensity activity

breaks in sedentary time were beneficially
associated with waist circumference (p<0.026),
BMI, p<0.026), triglycerides, p<0.029), and 2-h
plasma glucose (p<0.025) in 168 adults (Healy, et al,
Diabetes Care, 2008).
Jump to first page
Play Now! Homework Later!
 When children get home after school,
their brains are tired, but not their
bodies.
 They’ve had a long day in a
sedentary environment and need
to be active to let off steam.
 Instead of a snack, hand your child a glass
of water and send him outside to ride a
bike, skate, play ball or tag for about 30
minutes. Indoors he can dance, shoot
hoops with foam balls or skip rope.
 Then when he does homework, he’ll
concentrate better.
Sothern et al, Trim Kids, Harper
Jump toCollins,
first page2001
Homework in the News
 The American Academy of

Pediatrics reports that
programs such as the ―No
Child left Behind Act of 2001‖
and parents who push children
too hard and emphasize school
work result in a reduction in
unstructured playtime, which
may hinder emotional
development.
Jump to first page
Trim Kids Physical Activity Center
Imagine Station
Plastic tub filled with dress-up clothes
Microphone, drums, toy musical instruments
Puppets, marionettes, magician kits, various
stuffed animals
Batons, small flags, pom poms, streamers, hula
hoops
Foam mats and wedges, indoor tents
Hop scotch mat, action games like Twister,
Charades
Paddle balls, indoor ball toss games, hacky sack
Kid-safe dart boards or other target games
Indoor basketball hoop and soft foam balls
Jump ropes, skip-it, small kid-safe hand weights,
exercise stretch bands.
Jump to first page
The Inclusion of Indoor and Outdoor Physical
Activity Centers to Increase
Unstructured Play in 2-6th Grade Youth.
Students‟ participation when they were given access to
the outdoor physical activity equipment. (Highest = 1;
Lowest = 5; Mean ± SD: 1.64 ± 0.78)
Always Often Sometimes Seldom/Never
52.3% 29.4% 17.7% 0% / 0%
Students‟ participation when they were given access to

the indoor physical activity equipment. (Highest = 1;
Lowest = 5; Mean ± SD: 2.35 ± 1.06)
Always Often Sometimes Seldom/Never
17.7% 47.1% 23.5% 5.9% / 5.9%
The Wise Mind Study; Sothern,
Jump toetfirst
al, page
Obesity, 2006
Interactive Computer Games (ICG)
ICG is similar in intensity to light to moderate

traditional physical activities such as walking,
skipping, and jogging (Maddison R, Ped Ex Sci, 2007)
Playing ICG on a regular basis may have

positive effects on children's overall physical
activity levels. (Ni Mhurchu C, Int J Behav Nutr Phys Act. 2008)
Experienced players have higher energy

expenditure during varied ICG (Sell, J Am Coll Health,
2008).
Jump to first page
What is Dance Dance Revolution?
Active screen media device that transforms typical
sedentary screen time into physical activity
 Overweight children
expend more energy
than normal weight
children during Dance,
Dance Revolution
 Similar to a 12 minute
walking treadmill test
 Significantly increases
energy expenditure
High school students playing
when compared to DDR during PE class
traditional screen time.
Unnithan et al. (2006) Int J to
Jump Sports Med,
first page
In a recent study Dance Dance
Revolution was shown to:
• have a broader appeal among
different ages especially to
those who might shy away
from typical physical activity
• Has greatest ease of use
• Elicits higher energy
expenditure values compared
to similar devices (Lanningham-
Foster et al. (2006) Pediatrics) .
However, DDR alone is not sufficiently motivating to produce

sustained physical activity over time in children (Madsen, Arch
Pediatr
;). Adolesc Med, 2007). Melinda Sothern, LSUHSC School ofJump to first page
Public Health
Physical Activity as Treatment for
Overweight Children:
Learning Objectives
 Identify evidence-
based
recommendations
and or protocols
for physical
activity
Jump to first page
Evidence Based Studies Including Exercise in
Overweight Children
Physical Activity Interventions – Individual and
Family Based Programs (Grade I & II):
 A total of 47 studies evaluated exercise
interventions in overweight children
 24 RCTs; 13 other design
 10 RCTs examined the independent contribution
of exercise:
 8 showed significant reductions in adiposity
independent of other factors
 Only 1 randomized-controlled study examined
sedentary behavior (TV) versus increased
physical activity (Grade III)
J Am Diet Assoc.Jump
2006;106:925-945
to first page
Activity in School-Age Youth
Physically inactive youth:

 Incremental approach to reach the
60 minute per day
recommendation
 Increase activity by 10% per week
 Progressing too quickly is counter

productive and leads to injury
Strong, Malina, Blimkie, et al, J Pediatrics, 2005; 2008 U.S.
Jump to guidelines
first page
American Heart
Association Childhood
Obesity Summit
 Overweight youth should

be given realistic, easily
obtainable physical
activity goals
 Should not be compared to
normal weight peers
Daniels SR, et al. American Heart Association Childhood Obesity Research

Summit: Executive Summary. Circulation (2009) 119: 2114-2123.
Overweight Children: Learning
Objectives
 Discuss
motivational
strategies to
promote physical
activity.

Jump to first page
Motivating Overweight
Children to Increase
Physical Activity
Put Some
Pep in
Your Step
Jump to first page
The Pep Step
Head Up, Shoulders back!
If you lift your head you’ll

grow 5-6 inches (and look
25-30 lbs. lighter!)
Look fit and like you know

where you are going----
look important.
Walk fast and burn more

Melinda Sothern, LSUHSC School of Public Healthcalories. Jump to first page
How to Promote Physical
Activity in Overweight Youth
 Mastery Experiences: Set short-term, achievable
physical activity goals and provide activity rewards for
those achieved.
 Physiologic Feedback: Teach pacing techniques such
as breathing and heart rate monitoring; Re-evaluate the
child‟s condition every 3-6 months.
 Role modeling: Parents don‟t have to be thin but they
must set a good example by participating in physical
activities and reducing screen time.
 Knowledge Transfer: Enroll children in structured
dance, sport or movement classes. Make sure the
teachers are qualified and understand limitations
Social Cognitive Theory: Hunter, 1996; Sothern & Hunter, 1999; Sothern, Handbook of Pediatric Obesity: 2006
Jump to first page
Mastery
 Expose children to varied activities

in a non-intimidating and nurturing
environment.
 Encourage participation in aerobic
activities appropriate for age and
size.
 Realize that young children have
immature metabolic systems. Don‟t
impose adult exercise goals.
Sothern et al, Trim Kids, Harper Collins,

Class 1 ______(date)
Goal-setting and Action
Planning
My goal for this week is to:
_________________________________
_________________________________
1. Does it say exactly what I plan to DO?
2. Do I have control over it?
3. Can I tell when I’ve done it?
4. Does it say what I WILL do instead of
what I WON’T do?
5. Is is easy to do? Sothern et al, Trim Kids, Harper Collins, 2001
Physiologic Feedback
 Encourage children to self-monitor
physical activity and provide activity
rewards for goals achieved.
 Don‟t draw attention to unhealthy
activities with negative comments.
Instead, praise the child when they
choose active play instead of TV.
 Teach children that all movement is
physical activity and will burn calories.
Sothern et al, Trim Kids,
JumpHarper Collins, 2001
to first page
60-90
150-200

Jump to first page
What if the Parents say:
You know, I’m big,

my momma was big,
my grandma was
big…..We’re just big
people.
Sothern, et al, Trim Kids,

Jump to 2001
first page
Knowledge Transfer
 Parent Tip: Even if your child is

genetically designed to be overweight,
his or her environment can be adjusted
to combat this predisposition.
 Your child may become chubby even with
adjustments. He or she does not have to
be doomed to a life of ill health.
Role Modeling
 Families that play together, stay healthy

together.
 Reserve at least 1/2 day of each weekend
for family physical fitness.
 Alternate a game of family flag football
outdoors with games on TV. Play the 1st and
3rd quarters and watch the 2nd and 4th.
 Create and environment for active play both
inside and outside the home.
GENETICS PERMITS OBESITY.
ENVIRONMENT CAUSES OBESITY.
Melinda Sothern, LSUHSC School of Public Health Hill & Dietz
Jump to first page
The effectiveness of the following
strategies in the home on weight status
in children is unknown:
 Homework Limits
 Interactive versus standard computer
games:
 Dance, dance revolution
 Nintendo Wii
 Guitar Hero
 Use of instructional exercise DVD’s
 Bicycle use
 Outdoor neighborhood (tag) games Jump to first page
The individual contribution of the
following strategies in the home on
weight status in children is unknown:
 Alter the inside and outside home
environment – ―imagination station‖
 Music (dancing?) versus screen time
 Promoting active play prior to homework
 Frequent physical activity breaks – ―30-
minute rule (classy moves)‖
 Parent education – developmentally
appropriate activities
 Skill development – parent instruction
 Mainstreaming – organized activities with
healthy weight children Jump to first page
Overweight Children:
Learning Objectives
 Implement an age, gender

and developmentally
appropriate physical activity
plan tailored to the child‟s
medical condition, family
history and background

What is the
best
physical
activity for
overweight
children?
Jump to first page
Are Exercise Interventions Effective
in Obese Youth
 Active lifestyles among children should be
encouraged but there is little evidence as to
what type of interventions work best to address
this issue
 Few PA interventions have had an effect on BMI
 Advice given to children by their Primary Care
Physicians could increase PA levels
 More research is needed in children to prove
the effectiveness of such programs
Henderson M, et al. Exercise Interventions in Obese Youth: Are They Effective? J Ped
Endocrin & Metab 2008; 21: 823-26.
The best choice of physical
activity is one that the child
will most likely perform with a
high level of compliance.
 Expose overweight children to a variety of
physical activities in a nurturing, non-
intimidating environment.
 Individualize recommendations according
to the child’s:
 Medical & family history
 Current weight condition or obesity level
 Age
Jump to first page
Sothern, Handbook of Pediatric Obesity: Clinical Management, 2005
Hurray, I‟m still at
Trim Kids I‟m there! my goal
Pediatric Weight weigh!
Management
How long will

it take?
Level IV
Team Kids
Level III < 85th
Club
Level II > 85th% BMI
Level
> 95th% BMI
I
BMI
> 99th%
BMI
Start 10 wks 20 wks 30 wks 1 year 18 yrs.
Jump to first page
Intensity of Physical
Activity Melinda Sothern, LSUHSC School of Public Health
Percent of Maximal Oxygen Uptake

 %VO2 max mL/kg/min.
Percent of Heart Rate
 %HR max BPM
Speed
 Miles/kilograms per hour
Force (Resistance/Weight)
 Pounds/kilograms
Metabolic Equivalent (MET) Jump to first page
Moderate Intensity Progressive Exercise
Prescribed
Intensity of Exercise
70
60
50
40
%VO2
30
Max
20
10
0
Week 1 Week 5 Week 10
Normal Weight At Risk Overweight Severely Overweight

Jump to first page
Volume of Physical
Activity
Duration
 How long (minutes)
Frequency
 How often (days per week)
Jump to first page

Prescribed
Duration of Exercise
60
50
40
Min./ 30
Session
20
10
0
At Risk Overweight Severely Overweight

Jump to first page
Prescribed
Frequency of Exercise
6
5
4
Days/ 3
Week
2
1
0
At Risk Overweight Severely Overweight

Jump to first page
Table 1 – Moderate Intensity Progressive Exercise Prescribed

Duration of Exercise (minutes per session)
Level Week 1 Week 5 Week 10
Overweight 30 45 60
Obese 25 40 55
Severely 20 35 50
Obese
Table 2 – Moderate Intensity Progressive Exercise Prescribed

Frequency of Exercise (days per week)
Level Week 1 Week 5 Week 10
Overweight 3 4.5 6
Obese 2 4 5.5
Severely 1 3 5
Obese
Sothern, et al, 2006, Handbook of Pediatric Obesity: Clinical
Jump Management
to first page
Self Reported Increases in Physical Activity in
Overweight Youth after a 10-week Specialized
Exercise Program
90
80
70 Godin Leisure
Time
60 Weight
50
40
30
Baseline 10 weeks N=18; p<0.01
Melinda Sothern, LSUHSC School of Public Health Reed & Sothern, 2001; Sothern,
Jump 2005, 2006
to first page
Volume of Exercise
in Severely Overweight Children
2000
1800
1600
1400
1200 Goal
1000 Actual
Min.
800
600
400
200
0
Week 1 Week 5
Week 10
Reed & Sothern, 2001; Sothern, 2005, 2006 p < 0.0001
Jump to first page
Types of Physical
Activity Melinda Sothern, LSUHSC School of Public Health
Aerobic
 Endurance (longer durations)
Anaerobic
 Strength (weight lifting)
 Power (sprints, jumps)
Weight bearing
 Walking, jogging, running
Non-weight bearing
Jump to first page
Severely Overweight Children

(>99th BMI), 7-18 Years
 Limit access to TV/video/computer

 Recommended Aerobic Activities:
 Non-weight-bearing only such as
swimming, recline bike, arm
ergometer, seated (chair) aerobics
and seated or lying circuit training.
 NOTE: Guidelines should be readjusted every 10-15 weeks based on
 Parent training and fitness education

 Other emotional and dietary
concerns must be addressed during
treatment.
Sothern, 2000; Myers, et al, 1998; Strauss, 2000; Barlow & Dietz, 1998, von
JumpAlmen, 1985
to first page
Overweight Children (>95th BMI),
7-18 Years Melinda Sothern, LSUHSC School of Public Health

 Non-weight-bearing such as
swimming, cycling, strength/aerobic
circuit training, arm specific aerobic
dancing, arm ergometer (crank),
recline bike, and interval walking.*
 *Walking with frequent rests as necessary. Gradually work
up to longer walking periods and fewer rest stops.
 NOTE: Guidelines should be readjusted every 10-15 weeks
based on

Sothern, 2000;2001; Sothern, Handbook of Pediatric Obesity: ClinicalJump to first page
Management, 2006
Children at Risk for Overweight
Conditions (>85th BMI), 7-18 Years
 Weight-bearing such as brisk walking,
treadmill, field sports, roller blading, hiking,
racket ball, tennis, martial arts, skiing,
jump rope, indoor/outdoor tag games.
 NOTE: Guidelines should be readjusted every 10-15 weeks
based on evaluation results.
 Parent training and fitness

education
 Pacing Skills
Sothern, 2000; 2001; Sothern, Handbook of Pediatric Obesity: Clinical Management,
Teaching Pacing Skills
The
Metabolic
Engines
of
the Body
Mambo in New Orleans
How „bout those Saints?
8 and 0
We‟re Back and Better than Ever! Ya‟ll Come See Us….
Jump to first page
Time to
Cool Down
and Stretch
I Sting

Jump to first page
Provide
opportunities for
young children to
safely climb, run
and jump to
encourage the
development of
muscular strength
and endurance.
Sothern, 2001 Jump to first page

The Health Benefits of
Strength Training in Children
 Improved strength
 Increased power
 Improved muscular endurance
 Increased bone density
 Tendon-bone interface strength
 Improved motor performance
 Self-satisfaction
 Increased self-esteem
 Positive body image Sothern, 1999, 2001 Jump to first page
Strength Training and
Children
The prepubescent child is at
an increased risk of injury due to
a reduction in joint flexibility
caused by rapid growth in the
long bones.
The results of strength
training provide additional
resistance to sports injury in the
prepubescent child and reduce
the incidence of overuse injury.
Windows
of Opportunity
Show a 4-year old a
move and they‟ll
remember it for
years and years.
Strength training
develops muscle
intelligence, which
has numerous
long term
health benefits.
Melinda Sothern, LSUHSC School of Public Health Sothern, 2001 Jump to first page
Why Does Metabolism Improve
after Strength Training (ST)?
  fat free mass after ST

  sympathetic nervous
system activity after ST
  metabolic activity of fat
free mass after ST
Winett, & Carpinelli, Prev Med, 2001; Lemmer, et al, Med Sci Sp, Ex, 2001; Byrne & Wilmore, Int J Spo Nut ex Met,
2001; Treuth, et al, J Appl, 1995; Campbell, et al, Am J Cl Nut, 1994; Pratley, et al, J Appl Physio, 1994; Ivy, Ex Spo Sci
Rev, 1999; Kraemer, 2007; Talanian, 2007; Benson, 2007
Jump to first page
Skeletal Muscle Metabolism
Strength training
improves the ability of
the muscles to use fat
as a fuel (fat oxidation)
Improved fat oxidation is

associated with
improved glucose
metabolism and
decreased insulin
resistance.
Dr. Sothern’s Hero
Melinda Sothern, LSUHSC School of Public Health Kraemer, 2007; Talanian,Jump
2007; Benson,
to first page 2007
Overweight Children
Moderate aerobic exercise combined with high-
repetition resistance training and behavioral
modification are most efficacious for improving body
composition variables in overweight children.
A meta-analysis examined 30 childhood obesity
treatment studies that included an exercise intervention.
Significant decreases in body composition were

associated with programs including low intensity
aerobic and high-repetition strength training.
Melinda Sothern, LSUHSC School of Public Health LeMura & Maziekas, Med Sci Sports Exer, 2002
Jump to first page
Program, Diet and Behavior Modification
Sothern et al. Am. J. Public Health 2000
Controls = Aerobics;
Experimental = Aerobics + Strength
Weight (Kg)
70 Pre
60 Post
50
40
Controls Experimental
10-week Study (Retention: Experimental = 78.9%; Control = 35%)

Strength Training
Improves Lean Muscle and
Bone Mineral Content
Obese, prepubertal children ~ 10 yrs; randomized to
Diet alone (n = 41) (control group).
Diet plus strength training (n = 41) (training group)
75-minute strength exercise 3 times/wk
After 6 weeks, the children in the training group

showed significantly larger increases in:
Lean body mass (+ 0.8 kg [2.4%] vs. +0.3 kg [1.0%],
p < 0.05) than control group
Total bone mineral content (+46.9 g [3.9%] vs. +33.6
g [2.9%], p < 0.05) than control group
Melinda Sothern, LSUHSC School of Public Health Yu, et al, J Strength Cond
Jump to firstRes,
page 2005
A 16-wk resistance training program significantly
increases insulin sensitivity in overweight Latino
adolescent males at risk for type 2 diabetes
 Overweight Latino adolescent males (N=22) were randomly
assigned to 2/week resistance training (RT=11) or a non-
exercising control (C=11) for 16 wks.
 Strength by1-rep max; lean and fat mass by DEXA, and
insulin sensitivity by the frequently sampled intravenous
glucose tolerance test with minimal modeling.
 Significant increases in strength (P<0.05) and insulin
sensitivity in the RT compared to C group (45.1+/-7.3% in
the RT group versus -0.9+/-12.9% in controls [P<0.01]).
 Results remained significant after adjusting for fat and lean
mass (P<0.05).
Melinda Sothern, LSUHSC School of Public Health Shaibi, et al, Med SciJump
Sports
to firstExerc,
page 2006
Initial Exercise Guidelines for
Overweight Children
Recommended Strength Training:
2-3 days per week at 60-80% of 1Rep Max.
1-2 sets per exercise.
1 exercise for each major muscle group.
Recommended Flexibility Training:
5 days per week 15-30 minutes.
1 exercise for each major muscle group.
NOTE: Guidelines should be readjusted every 10-15 weeks based on evaluation
results.
The MPEP Pump
Jump to first page

Teaching Strength and
Flexibility
•The Fast Five:
Hot Seat (legs)
Raise the Roof (shoulders)
Row your boat (back and arms)
Off the wall (chest and arms)
Crunches (stomach)
Jump to first page
Flexibility
Pull Your Own Weight:

Triceps dip
Pull up
Modified lunge
Wall push up
Sothern, Trim Kids, 2001;Handbook of Pediatric Obesity: Clinical Jump to first page
Management, 2005
Flexibility
Band Aid for Muscles

Seated row
Bicep curl
Standing row
Squat
Sothern, Trim Kids, 2001;Handbook of Pediatric Obesity: Clinical Jump to first page
Management, 2005
Flexibility
The Flex Test
Partner observation:
Head
Shoulders
Back
Knees
Jump
Sothern, Trim Kids, 2001;Handbook of Pediatric Obesity: Clinical to first page
Management, 2005

Sothern, Trim Kids, 2001;Handbook of Pediatric Obesity: Clinical Management,
Summary of Evidence Based Studies
Including Exercise in Overweight Children
1984-2004 Evidence-based Pediatric Obesity
Treatment Studies (Individual and Family
Based – improvement in weight status):
Recommendations:
 Sufficient research to routinely recommend
exercise in combination with diet and
behavioral counseling.
 More research is needed to support
recommending exercise alone
 More research is needed to support
reducing sedentary behaviors as opposed
to increasing physical activity.
J Am Diet Assoc. 2006;106:925-945
Jump to first page
Lifestyle Recommendations by Weight
Classification for Management of Obesity
in Youth (ages 7-18 years)
Weight Classification Healthy Weight (5th – 84th % BMI)
Level of Behavioral Receive support in maintaining or establishing

healthy lifestyle (prevention) behaviors
Treatment
Dietary Counseling Family nutrition education and parent training

emphasizing appropriate food portions , reduced
sugar and saturated fat, increased fruits and
vegetables, and recommended dairy and fiber
intake
Physical Activity Limit screen time; recommended physical activity
requirements: 60 minutes of daily moderate to
vigorous physical activity (3 days/week of
Melinda Sothern, LSUHSC
School of Public Health vigorous activity) and bone and muscle
strengthening activities
Adapted from Barlow, Pediatrics, 2007; Sothern, Handbook of Pediatric Obesity, Taylor and Francis, 2006
Jump to first page
*Note: Guidelines should be readjusted every 10-15 weeks based on evaluation results
Lifestyle Recommendations by Weight Classification
for Management of Obesity
Weight Classification Overweight (85th – 94th % BMI)
Level of Behavioral Some children should receive prevention

counseling (if no evidence of health risk),
Treatment whereas others (evidence of health risk) should
receive more-active interventions
Dietary Counseling Family nutrition education and parent training in
combination with portion control methods or
balanced calorie meal plans emphasizing
appropriate food portions , reduced sugar and
saturated fat, increased fruits and vegetables,
and recommended dairy and fiber intake
Physical Activity Limit screen time; incremental approach to
increase physical activity volume; weight bearing
aerobic activities (e.g. field sports, tennis, jump
Melinda Sothern, LSUHSC rope); pacing skills; parent training; fitness
School of Public Health
education
Jump to first page
Weight Classification Obese (>95th% BMI)
Level of Behavioral Most children considered obese should be
advised to focus on weight control practices.
Treatment
combination with balanced hypocaloric diets
emphasizing appropriate food portions, reduced
sugar and saturated fat, increased fruits and
vegetables, recommended dairy and fiber intake,
and Low GI Diet
increase physical activity volume; alternate
between weight-bearing and non-weight-bearing
Melinda Sothern, LSUHSC activities (e.g. swimming, cycling, seated or lying
School of Public Health circuit training); parent training; fitness education
Jump to first page
Weight Classification Severely Obese (>99th % BMI)
Level of Behavioral Other emotional and dietary concerns must be

addressed
Treatment
combination with altered macronutrient dietary
approaches as follows: Low GI Diet, Atkins Diet,
protein modified fast diet followed by balanced
hypo-caloric diet
increase physical activity volume; non-weight-
bearing activities (e.g. swimming, cycling, seated
or lying circuit training); parent training; fitness
Melinda Sothern, LSUHSC
School of Public Health education
Jump to first page
Physical Activity as Treatment
for Overweight Children:
Learning Objectives
 Identify
biochemical,
anthropometric,
behavioral and
fitness outcomes
related to physical
Melinda Sothern, LSUHSC School of Public Health activity Jump to first page
Effects of Diet and Physical Activity in Short
term Studies on Health Outcomes
 Percent Fat 
 Resting Energy expenditure NC
 Oxygen Uptake (VO2)

 absolute NC
 relative 
 Total Cholesterol and LDL 
 Growth Velocity 
 IGF-1 
 Insulin 
 Leptin 
 Estradiol Melinda Sothern, LSUHSC School of Public Health  Jump to first page
Childhood Obesity Treatment
Long-term Studies – Weight Status
Authors Age Intervention Outcome

Epstein 6-12 Parent/child -19.7% @ 10 yrs
Braet 9-12 Behavioral vs advice -17.3 @ 4.5 yrs.
Nuutinen 6-15 Group vs Individual -11.7% @ 5 yrs.
Epstein 6-12 Parental obesity NS @ 10 yrs
Epstein 6-12 Exercise + diet NS @ 10 yrs
Epstein 6-12 Lifestyle exercise -15.3% @ 10 yrs
Ten months of exercise improves general and visceral
adiposity, bone, and fitness in black girls.
8-12 year olds participated in 30 minutes homework/healthy
snack time and 80 minutes of physical activity (PA):
25 m skills instruction, 35 m aerobic PA, and 20 m
strengthening/stretching).
Compared with the control group, the intervention group had:

 a relative decrease in %Body Fat (p < 0.0001), BMI (p <
0.01), Visceral Adipose Tissue (p < 0.01)
 a relative increase in BMD (p < 0.0001) and Cardiovascular
fitness (p < 0.05).
Higher attendance and heart rate were associated with

greater increases in BMD (p < 0.05) and greater decreases in
%BF (p < 0.01) Barbeau,Jump
et al, Obesity,
to first page 2007
Weight and Body

Mass Index after
Diet and Exercise
They let
* me play!
80
70
*
60
50
40
*
30
20
*
10
0
Baseline 10 weeks One Year
Weight BMI
Limitations: Non-randomized, repeated

measures clinical outcome trial.
* p < 0.001 (RM ANOVA) Baseline vs. 10ks & 1-yr.
NS =10 weeks vs. one year. Sothern,et al,Jump
Actato first page 2000
Pedia,
Maximal Oxygen Uptake and Heart Rate after
Diet & Physical Activity in Severely Overweight
Children (Sothern, Loftin, et al J Invest Med, 2000, and 1999)
Body Mass Index (Kg/m2.)
* VO2max mL/kg/min.
23 22.5 *
35 34.1 22
34
33 21
32
31 * . 20 19.2
30 29.4 19
29 18
28
17
* P<0.001
27 Baseline 10 weeks
* P<0.001
Baseline 10 weeks
N=11; Age: 12.3(1.9) Range: 7-14 years N=11; Age: 12.3(1.9) Range: 7-14 years
1.6 1.54VO2max L/min. 1.54 Resting Energy Expenditure

1.4
1.2 1800 1685 1705
1700
1
1600
0.8 1500
0.6 1400
0.4 1300
0.2 1200
1100
0
Baseline 10 weeks 1000
Baseline 10weeks
N=11; Age: 12.3(1.9) Range: 7-14 years N=10; Average Age: 10.8 years (Range: 7-15 years)
Jump to first page
Interdisciplinary Weight Reduction Program
including Progressive, Submaximal Exercise
Severely Overweight Adolescents:

N = 55; M = 22; F = 33; 6-12 months
Body Mass Index -6.4%(M); -5.9% (F)
Fat mass -10.1(M); -11.4 (F)%
Total lean body mass was unchanged
Anaerobic endurance significantly
improved in all.
Aerobic Fitness (V02maxLM)
increased in boys only.
Melinda Sothern, LSUHSC School of Public Health Dao, Frelut, Peres, et Jump
al, Int‟l J Obes,
to first page 2004
Effects of a 1-year weight management program on
body composition and metabolic parameters in
overweight children
 Randomized controlled trial (N=209; 8-16 yrs;
mixed ethnic group
 12 month (m) intensive family-based program including
structured exercise, nutrition, and behavior modification.
 135 (60%) completed 6 m, 119 (53%) completed 12 m
 6-m improvements were sustained at 12-m in weight
management vs control (mean [95% confidence interval]):
 BMI (-1.7 [-2.3 to -1.1] vs +1.6 [0.8 to 2.3]);
 Body fat (-3.7 kg [-5.4 to -2.1] vs +5.5 kg [3.2 to 7.8]); and
 HOMA-IR (-1.52 [-1.93 to -1.01] vs +0.90 [-0.07 to 2.05]).

Savoye, ettoal,
Jump firstJAMA,
page 2007
Trim Kids Success at Riverfront
Des Moines YMCA
 A pilot program started in Sept., 2004
 Referrals from physicians and school nurses
 29 children registered; 24 completed
 Age range: 7-17 years
 Males = 9; Females = 15
 BMI for all was >95th % and was reduced after
the program
 Total weight loss: 196.6 lbs.
 Total waist circumference lost: 92 inches
Melinda Sothern, LSUHSC School of Public Health Health & Fitness, Spring,
Jump to first2007
page
Trim Kids Implemented in YMCA
Centers in South Louisiana
 A pilot program started in July, 2007
 LSUHSC SPH provided professional training
 Intervention programs were launched in
February, 2008 in seven locations:
 Baton Rouge, East Jefferson, West Bank,
Northshore, Luling, Uptown, Downtown
 Currently in week 5 of the fourth 12-week program
 Approximately 15-20 families per site
 Weight losses range from 5-35 pounds to date
 Statewide initiative will begin in November, 2008
Summary
Interventions for
overweight children
and their families
should be fun and
entertaining.
“Provide parent
training while you play
with the kids”
for more
information:
msothe@lsuhsc.edu
Trim Kids and
Handbook of Pediatric Obesity
available at www.amazon.com Jump to first page
Trim Kids
The Program
Community Guide Finding
Products
Time Required
Intended Audience
Suitable Settings
Required Resources
About the Study
Program Scores
Dissemination Capability
Cultural Appropriateness
Age Appropriateness
Gender Appropriateness
Research Integrity
Intervention Impact
Publications Preview and Order Materials from the Publisher
Jump to first page
 Trim Kids Fitness
 Fun Zone DVD
 Dr. Melinda S. Sothern, and
her lively team of Trim Kids,
stretch, walk, kick and
dance their way to better
health.
 Upbeat, ability-based
workouts designed to make
exercise fun.
 Three aerobic routines, for

the beginner, intermediate,
and advanced child,
 Strength and flexibility

training workout for all
fitness levels.
Email to: kvaphd@juno.com

Jump to first page
Additional Resources:
Ed. Melinda S. Sothern, Stewart Gordon, T.Kristian von Almen

(CRC Press (www.crcpress.com) Email: orders@taylorandfrancis.com
http://www.crcpress.com/shopping_cart/products/product_detail.asp?sku=DK5832&parent_id=&pc
Jump to first page
Additional Resources
Ed. Melinda S. Sothern, Michael I. Goran

(CRC Press (www.crcpress.com) Email: orders@taylorandfrancis.com
Jump to first page
Additional Resources:
Louisiana Public Broadcasting System
(PBS) one hour documentary, "Kids
Trying to Trim Down", and a series of
six 30-minute segments, ―Kids Trimming
Down‖ on healthy eating, physical activity
and family behavioral counseling.
Website: www.lpb.org

Acknowledgements
The Louisiana State University Health Sciences Center, New Orleans, LA
School of Public Health, Administration, Faculty and Staff
Eric Ravussin, PhD
Health and Performance Enhancement (HAPE)
Louisiana State University (LSU) Pennington Biomedical Research Center (PBRC)
Claude Bouchard, PhD, Donna Ryan, MD, Frank Greenway, MD
LSU PBRC
Mark Loftin, PhD
Dept. of Human Performance & Health Promotion, LSU of New Orleans
John Udall, M.D., Ph.D.,
Dept. of Pediatrics, LSU Health Sciences Center & Children‟s Hospital
Heidi Schumacher, RD, LDN
Children‟s Hospital of New Orleans, Co- Author, Trim Kids
Kris von Almen, PhD,
Co-author, Trim Kids
William Dietz, MD, Michael Goran, PhD & the Pediatric Obesity Interest Group (POIG)
Hit the Road, Jack!
I
Ray I
Charles Ray
Charles I
Ray
Charles

Jump to first page
Additional
Information

Jump to first page
If you
let me play…
I will like myself more.
I will have more self
confidence.
I will be less likely
to get cancer.
I will be less likely
to get heart disease
I will be less likely to.
Melinda Sothern, LSUHSC School of Public Health become an obese adult.
Jump to first page
Physical Activity as Treatment for Overweight
Children: Learning Objectives
 Identify appropriate and reliable
physical activity assessment tools
 Assess and evaluate physical activity
level
 Identify physiologic and metabolic
factors that limit physical activity
 Identify evidence-based
recommendations and or protocols for
physical activity
 Discuss motivational strategies to
promote physical activity
Jump to first page
Physical Activity as Treatment for Overweight
Children: Learning Objectives (continued)
 Implement an age, gender and
developmentally appropriate physical
activity plan tailored to the child’s
medical condition, family history and
background
 Identify biochemical, anthropometric,
behavioral and fitness outcomes
related to physical activity
 Recognize when a referral to an
appropriate health professional is
warranted.
Jump to first page
Overweight Children: Learning
Objectives
 Recognize when a
referral to an
appropriate health
professional is
warranted.

Overweight Children
with Special Needs:
.
Important Questions
What are the child‟s cognitive
abilities?
What are the child‟s social skills?
How does the condition and
treatment impact stamina?
Does the child have special
nutritional needs? Jump to first page
Recommendations from the American
Academy of Pediatrics to Prevent Obesity in
Children with Risk Factors
Health supervision (Physical Activity)
 Use change in BMI to identify rate of
excessive weight gain relative to linear
growth.
 Routinely promote physical activity, including
unstructured play at home, in school, in child
care settings, and throughout the community.
 Recommend limitation of television and video
time to a maximum of 2 hours per day.
American Academy of Pediatrics. Pediatrics. 2003;112(2):424-430.
Evidence-based Recommendations for Exercise
in Overweight Youth
 Type or Mode
Play oriented in younger children
Continuous movement games, exercise
machines, swimming, aerobic dance,
strength training in older children
 Intensity
60-80% Max HR (moderate to vigorous)
 Duration and Frequency
30-50 minutes per session at least 3
days per week
Owens, Handbook of Pediatric Obesity: Clinical Management,
Jump to first page
in press
Proportion of Youth Watching 3 Hours
or More Television per Day
80
70
60
Percent
50
40
30
20
10
0
Girls Boys African Caucasian Low SES High SES
American
Melinda Sothern, LSUHSC School of Public Health McMurray et al., Obesity Res 2000
Jump to first page
Today
Only 50% of children regularly
participate in moderate-to-vigorous
physical activity.
Only 36% of children have daily PE.
75% of pediatricians report that

unstructured play has decreased.
97% of pediatricians report that time in front of

computer/TV replaces unstructured play.
Youth Risk Behavior Survey, Physician Specialty PanelHarris Poll Online, 2005
Percentage of Youth Participating in
Vigorous Physical Activity
80
70
Percentage
60
50 Boys
40 Girls
30
11 12 13 14 15 16 17 18
Age (Yr) USDA 1998
Jump to first page
RELATIONSHIP BETWEEN HOURS OF
TV OR VIDEO GAME PLAY
& BODY MASS INDEX
None >2 Hours
Body Mass Index
23
22
21
20
19
18
17
Girls Boys Girls Boys
TELEVISION VIDEO GAMES
Melinda Sothern, LSUHSC School of Public Health McMurray et al.,Jump to first page
Obesity. Res. 2000
Exercise Tolerance, Physical
Activity in Overweight Youth
25 girls; 20 boys
Age: 11.9 +/- 3.0 yrs., 13.7 +/- 2.5 yrs
Exercise tolerance < minimal levels
in 64% girls; 75% boys.
Energy expenditure < minimal levels
in 80% girls; 65% boys.
> 2 hours TV watching: 76% girls, 70% boys

Only 40% of girls, 70% of boys walked to
school.
Hussey,Jump
et al,to first
Ir Medpage J, 2006
Impaired Health-Related Quality of Life for
Severely Overweight Children and
Adolescents vs Healthy and Cancer Samples
Child self-report total score
Odds Ratio Obese vs Healthy Obese vs Cancer
Physical 5.0 (3.4-8.7) 1.0 (0.6-1.7)

health score
Social 5.3 (3.4-8.5) 1.8 (1.0-3.1)
Functioning
School 4.0 (2.4-6.5) 1.1 (0.6-2.0)

Functioning
Melinda Sothern, LSUHSC School of Public Health Schwimmer,Jump
et al,toJAMA,
first page2003
Physical Activity
and Children
In Native American Children, a decrease in PAL
may follow, not precede, overweight conditions.
Obesity @ 5 years is associated with
increased TV, decreased sports but not PAL.
Obesity @ 10 years is associated with
increased TV, decreased sports
and PAL.
Salbe, Weyer, Harper, Lindsay, Ravussin
& Tataranni, Pediatrics, 2002
Obesigenic Families
 A recent study examined the self-reported physical
activity and dietary intake patterns of parents and
changes in weight status (body mass index and
skin folds) over 2 years in offspring.
 Girls of parents with high dietary intake and low

physical activity (obesigenic) had significantly
greater increases in weight status.
 Family environment may explain increased weight

status in children over and above genetic
susceptibility.
Davison and Birch, Int‟l J of Ob 2002
Tune out Tuesday‟s
 Family ―Turn
Off the TV‖
Days
 For one month
families turn off
the TV and
computers
every Tuesday.
Jump to first page
Homework in the News
 ―Several new books and studies have
documented the negative effects of too much
homework and found no corresponding
improvement in academic performance‖ Wall
Street Journal
 ―Make homework assignments worthy of our
students’ time‖, Gunn High School, Palo Alto,
CA.
 The Greenville, South Carolina school district
limits nightly homework and it’s effect on the
final grade.
 ―I stopped crying so much and now I have
more time to play.‖ Sammi, Sparhawk, Mass.
Initial Physical Activity Strategies by
Medical History, Age & Weight Condition
Level Age Physical Activity Approach

Family counseling, fitness education, free
6
Normal Wt
Obese Parent play, reduce TV, parent training
>85th Structured weight bearing activities, free

BMI 7-18 play, reduce TV, parent training
>95th Alternate non-weight bearing activities, free

BMI
7-18 play, reduce TV, parent training
>99th *Non-weight bearing activities, free play,

BMI
7-18 reduce TV, parent training
*Close medical supervision required (Sothern, Handbook of Pediatric Obesity:
Clinical Management , 2005) Melinda Sothern, LSUHSC School of Public Health
Jump to first page
Normal and Overweight Children
 6 Years With Parental Obesity
 Regular visits with the pediatrician to
monitor growth and development
 Increased opportunities for unstructured
physical activity - free play
 Create an environment inside the home
that promotes active play
 Create an environment outside the home
that promotes play
Melinda Sothern, LSUHSC School of Public Health American Academy ofJump
Pediatrics
to first page
What Does the Research Say?
1985-2005 Interventions for Childhood
Overweight: Evidence for the US Preventive
Services Task Force
Recommendations:
 Insufficient evidence for the effectiveness of
behavioral counseling or other preventive
interventions with overweight children and
adolescents that can be conducted in primary
care settings or to which primary care
physicians can make referrals.
 More quality research is needed.
Whitlock, Williams, Gold, et alJump
Pediatrics,
to first page 2005
What Does the Research Say?
2004 Systematic Review and Meta
Analysis
645 manually searched, 45 considered, of which
14 studies included (N = 481 overweight boys
and girls, ~12 yrs). Few studies were robust.
Recommendations:
Aerobic exercise of 155-180 min/weeks at
moderate-to-high intensity is effective for
reducing body fat in overweigh youth.
Effects on body weight and central obesity are
inconclusive.
Melinda Sothern, LSUHSC School of Public Health Atlantis, et al, Int’l
Jump J
to Ob, 2006
first page
Physical Training Improves Body Composition
of Black Obese 7-11 yr Girls
(Gutin, et al, Ob Res, 1995)
Variable Lifestyle Lifestyle Physical Physical
Pre (N=10) 10 wk Training Training
Pre (N=12) 10 wk
BMI 26.8 (4.7) 26.7 (4.9) 27.9 (5.2) 27.1 (5.1)*
(kg/m2)
Fat (%) 43.35(8.8) 42.94 (9.1) 42.83 (7.9) 41.41(8.8)*
Fat free 28.14(4.1) 29.05(3.9)** 30.69 (7.3) 31.48(7.5)**

mass (kg)
Peak Heart 187.2(11.8) 188.2(11.7) 194.8(17.1) 190.3(17.2)

Rate (bpm)
Peak VO2 25.3 (4.7) 24.6 (3.2) 25.8 (4.9) 26.4 (6.6)
mL/kg/min.
*p<0.05; **p<0.01
Body Composition and Resting Energy
Expenditure after Diet and Physical Activity in
Severely Overweight Children (Olivier, Sothern, et al, Int‟l J
Obes, 2002; Sothern, Loftin, et al J Invest Med, 2000
Fat Body Weight Bone)Mineral Content
43.3 2.89 2.88
*
45 3
40 35.7 2.5
35 1.98 1.99
30 28.2
*
22.6
2
Kg. Kg.1.5
25
20
15 1
10
5 0.5
0 0
Baseline 15 weeks
* P<0.0001 Baseline 15 weeks
Age: 5-11 years (N=27) Age: 12-17 years (N=19)
Age: 5-11 years (N=27) Age: 12-17 years (N=19)
Lean Body Weight
Maximal Heart Rate
45 43.1 43.6
40 200
35 30.3 30.9
30 190
181
25 177
Kg.
20 kcal 180
15
170
10
5 160
0
Baseline 15 Weeks 150
Age: 5-11 years (N=27) Age: 12-17 years (N=19) Baseline 10 weeks
Jump toyears
first page
Melinda Sothern, LSUHSC School of Public Health N=11; Age: 12.3(1.9) Range: 7-14
Sample Annual Multi-Disciplinary Clinic Budget
 Income
 Patient fees
 (40 children @ $40/wk [48 wks]) = $76,800
 Insurance/Medicaid payments = ???
 Expenses
 Intervention Staff 4 X $5,000/yr) = $20,000
 Blood Tests (40 X 2 X $650) = $52,000
 Physician fees (40 X $350) = $14,000
 Educational Supplies (40 X $200)= $8,000
Total Expenses: $94,000
Jump to first page
Sample Annual Trim Kids Program Budget
 Income
 Patient fees (60 children @ $75/12-week
session [4 sessions] = $4,500.
 Expenses
 Intervention Staff (3 X $960./yr [$20/hr X
48 weeks]) = $2,880.
 Educational Supplies (60 X $11) = $ 660.
 Miscellaneous Supplies (charts) = $ 120.
Total Expenses: $3,660.
Jump to first page
Scatterplot of Heart Rate peak & Body
220 Weight in Obese & Normal Weight
Female Youth
210
200
HR (bpm) peak
190
180
170
160 r = - 0.53
150
20 40 60 80 100 120 140 160
Body Weight (kg)
Melinda Sothern, LSUHSC School of Public Health Loftin & Sothern, Clinical
JumpPediatrics,
to first page 2003
Relationship of Physical Activity to
Total Cholesterol
160
140
P A (G odin S c ore)
120
100
80 r = 0.24; NS
60
40 r = - 0.76; p < 0.05
20
0
100 120 140 160 180 200 220
T otal C holes terol (mg /dL )
non-C a Ca Jump to first page
Relationship of Physical
Activity to Diastolic Blood
Pressure
160
140
P A (G odin S c ore)
120
100 r = - 0.57; p < 0.05
80
60
r = - 0.28; NS
40
20
0
40 50 60 70 80 90
Dias tolic B lood P res s ure (mmHg )

non-C A (n=13) C A (n=15) Jump to first page
Exercise Training and

Adipose Tissue Metabolism
Exercise improves oxygen transport
promoting a preference for lipids as fuel
The increased capacity to release
and replenish lipid substrates is due to:
Improved response to catecholamine
stimulation
 number of glucose transporters
 glucose into triglycerides
 lipoprotein lipase activity
Byrne & Wilmore, Int J Sport Nutr Ex Met, 2001; Hurley & Hagberg, Ex & Sp Sci Rev., 1998;
Talanian, et al, 2007; Tonkonogi, et al, 2000; Kelley, D., 1999; Wilmore
Jump toand
firstCostill,
page 1994
FIG. 1. Line graph of the changes in insulin resistance [M(lbm)] for each subject before
and after the 8-wk exercise training period
Bell, L. M. et al. J Clin Endocrinol Metab 2007;92:4230-4235

Jump to first page
Copyright ©2007 The Endocrine Society
Fig 5. A, Resting and maximal HR

during the cycle test
Norman, A.-C. et al. Pediatrics

2005;115:e690-e696
Jump to first page

Copyright ©2005 American Academy of Pediatrics
Volume of Exercise
in Children at Risk for Overweight
1800
1600
1400
1200
Goal
1000
800 Actual
600
400
200
0
Week 1 Week 5 Week 10 p < 0.0001
Melinda Sothern, LSUHSC School of Public Health Reed & Sothern, 2001; Sothern,Jump
2006to first page
Trim Kids™ Class Schedule
Medicine Nutrition Behavior Exercise
Return Calls
4:00-4:30 Set-up
Nurse Check Food Talk with Check Exercise

4:30-4:50 Supervises Records Parents Review Cards
Weigh-In Charts
4:50-5:00 Group Group Group Group

Review Charts Nutrition Return Calls Review Charts
5:00-5:30 Session Review Charts Return Calls
Physician Q&A Clean-up Behavior Set-up Exercise

5:30-6:00 or Session Session
Physician Q&A Clean-up Exercise

6:00-6:30 or Session Session
6:30-7:00 Clean-up Clean-up

Jump to first page
Flexibility
The MPEP Pump
The Fast Five
Band Aid for Muscles
Pull Your Own Weight
Flex Test
Jump to first page
Muscular Strength is an Independent
Predictor of Lower Insulin Resistance
in Children
In 10-15 yr.olds (N = 126) upper body

strength and waist circumference were the
only independent predictors of insulin
resistance, accounting for 39% of the
variance (p < 0.001).
Children in the highest and middle tertiles
of absolute upper body strength were 98%
less likely to have high insulin resistance
than those with the lowest strength, adjusted
for maturation and central adiposity, body
mass (OR = 0.019; p = 0.003).
Melinda Sothern, LSUHSC School of Public Health Benson, et al, Int’l Jump
J Ped Ob,
to first page2006
Functional Levels of Children with
Neuromuscular Diseases
Known diagnosis without symptoms during
routine activities Melinda Sothern, LSUHSC School of Public Health
Low endurance, strength and overwork weakness

Ambulatory without aids
Easy fatigue, disuse weakness, reduced endurance,
mild contractures, overwork weakness
Ambulatory, marked weakness, contractures
Limited ambulation, poor endurance, disuse
weakness, overwork weakness
Functional wheelchair user Goldberg, 1995
Restrictive lung disease, cardiomyopathy Jump to first page

Exercise and Medically
Fragile Children
Arthritis
Exercise should progress in a slow, gradual manner
Active and active-assisted range of motion exercise to
promote flexibility using slow rhythmic movement
Isometric and isotonic exercise to improve strength
Recreational activities and physical activity breaks every
2 hours to prevent inactivity stiffness.
Appropriate activities include:
Modified strength training
Aquatic Exercise
Cycling
Modified dancing
Fragile Children
Asthma
Children with asthma typically have low fitness levels.
Exercise triggers acute asthma which may occur during
but, usually 5-10 minutes following the activity.
Use standardized exercise tests to determine fitness
Follow ACSM guidelines
Appropriate activities include:
Low asthmogenic sports such as: tennis, handball,
diving, karate, golf, baseball, sprinting, gymnastics
Breathing and postural exercises to prevent “tight
posture” associate with under-used diaphragm
Jump Goldberg,
to first page 1995
Fragile Children
Hypertension
Children with severe uncontrolled hypertension or
target-organ involvement should not participate in
competitive sports.
Children with controlled hypertension and no target-
organ disease may participate in moderate high dynamic
and low static competitive sports.
Children with controlled hypertension and evidence of
left ventricular hypertrophy or renal impairment may
participate in low intensity activities such as bowling or
golf.
Melinda Sothern, LSUHSC School of Public Health Goldberg, 1995
Jump to first page
 Physical activity interventions in school settings
did not improve BMI among children.
 Potential reasons: volume of PA, adherence to
program, or diet
 Keep PA in schools to promote overall health but
more research is needed to establish its ability to
prevent childhood obesity in school settings
 Future interventions should focus on improving
diet
 A well balanced diet may help improve BMI more than
physical activity alone
Harris KC et al. Effect of school-based physical activity interventions on body mass index in children: a meta-analysis. CMAJ 2009;
180(7): 719-26.
 Causes Childhood Obesity:
 improper diet (junk food, parents not regulating what
children eat, low cost of unhealthy food
 lack of activity-children have more sedentary lifestyles
 Potential ways to prevent Childhood Obesity:
 Physicians taking a more active role in health
promotion & education for parents, children and
school systems
 Limit junk food advertisements directed towards
children
 Federal initiatives (DHHS)
 Increase opportunity for PA in schools outside of PE
Wieting MJ. Cause and Effect in Childhood Obesity: Solutions for a National Epidemic. J Am Osteopath Assoc 2008; 108(10):
545-52. Jump to first page
 Review of interventions aimed at promoting

PA in children and adolescents
Adolescents: multicomponent interventions
including school and family/community involvement
Children: some evidence supporting an effect of
environmental interventions to increase PA but
more evidence needed
 Further research focusing on adolescent
ethnic minorities and preschool children
 Future research should include:
rigorous study designs
adequate sample sizes
assessment of long-term maintenance of behavior
Van Sluijs E, et al. Effectiveness of interventions to promote physical activity in children and
adolescents: systematic review of controlled trials. Jump to first page
LAZY BOY

Physical Activity As Treatment For Childhood Overweight Conditions - Melinda Sothern

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Physical Activity As Treatment For Childhood Overweight Conditions - Melinda Sothern

Încărcat de

Drepturi de autor:

Formate disponibile

Physical Activity as

Treatment for Childhood

Melinda S. Sothern, PhD

Melinda Sothern, LSUHSC School of Public Health

Children are 6 times more likely play

Only 47% of children report riding bikes

Only 6% of children report playing

DiNubile, 1993 Jump to first page

Kalish, 2007; Hillman, 2006; USDA, 1998 Jump to first page

Let the Children Play!

Melinda Sothern, LSUHSC School of Public Health

American Heart Association

 Engage professionals across multiple

Daniels SR, et al. American Heart Association Childhood Obesity Research

Physical Activity Rating

Godin Leisure-Time Exercise Questionnaire

b) Moderate Exercise (>15 min.)

c) Mild Exercise (>15 min.)

Physical Activity Risk Questionnaire

Melinda Sothern, LSUHSC School of Public Health

 It is also dependent on the genetic

Characteristic Slow-twitch Fast-Twitch(a) Fast-Twitch(b)

Force/size Low High Highest

Fatigue time Low High Highest

 The prolonged impact of physical activity

Start End End

Chronic Response of Physical Activity

Long-term exercise training may:

Endurance trained muscle stores more

Oxidative enzyme activity increases

Melinda Sothern, LSUHSC School of Public Health

Robinson, 1999; Sothern, 2001; Salbe,

Research sponsored by: NICHD Jump to first page

Exercise Tolerance in Children with Increasing

Severe (>99th% BMI) Overweight (>95th%BMI)

Heart Rate during Walking in Children

"They have flatter feet, collapsed arches,".

Jump to first page

Norman, A.-C. et al. Pediatrics 2005;115:e690-e696

Excess Fat and Exercise Performance

Sothern, 2001; Salbe, 2002

Melinda Sothern, LSUHSC School of Public Health

Increase After-School Exercise or Decrease Sedentary Activity

 Flex at Your Desk

“ Dancing with myself, I’ll be dancing

 Flex at Your Desk

 Increased moderate-to-vigorous intensity activity

 The American Academy of

Students‟ participation when they were given access to

ICG is similar in intensity to light to moderate

Playing ICG on a regular basis may have

Experienced players have higher energy

However, DDR alone is not sufficiently motivating to produce

Physically inactive youth:

 Increase activity by 10% per week

 Progressing too quickly is counter

 Overweight youth should

Daniels SR, et al. American Heart Association Childhood Obesity Research

Melinda Sothern, LSUHSC School of Public Health

If you lift your head you’ll

Look fit and like you know

Walk fast and burn more

 Expose children to varied activities