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ORIGINAL ARTICLE
Year :   |  Volume :   |  Issue :   |  Page :

Long Term Lifestyle Modifications on Submaximal Exercise Tolerance Test in Overweight Children, Tamil Nadu, India


1 SRM College of Physiotherapy, SRM Institute of Science and Technology, SRM Nagar, Kattankulathur, Kancheepuram District, Chennai 603203, Tamil Nadu, India
2 Department of Paediatrics, Karpaga Vinayaga Institute of Medical Sciences and Research Centre, Maduranthakam 603308, Tamil Nadu, India

Date of Submission30-Sep-2022
Date of Decision18-Oct-2022
Date of Acceptance21-Oct-2022

Correspondence Address:
Devadhason Malarvizhi,
SRM College of Physiotherapy, SRM Institute of Science and Technology, Chennai 603203, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnpnd.ijnpnd_75_22

   Abstract 


Background: The ability of the body to maintain continuous rhythmical exercise is referred to as cardio-vascular endurance. Based on previous longitudinal studies, obese children have a higher chance of becoming overweight adults in future. So this study was examining the impact of a school-based lifestyle modifications intervention on overweight and health outcomes among school children for a period of one and a half years. Methodology: The study design was randomized control trial 145 overweight children randomly recruited from 1300 healthy children. Seventy three overweight children from first school was Group A Experimental group and 72 overweight children from second school was Group B Control group. Participants in the study had an average BMI of 85 to 95 percentiles for their age and sex range, and they had to be 11 to 15 years old. Group A was treated with Lifestyle modifications like exercises, nutritional guidelines, and active lifestyle methods along with pamphlet. Group B was given oral instructions and given pamphlet with all instructions. 6MWT was used as an outcome measure to test submaximal exercise tolerance. Results: Group A showed significant improvement in all parameters like distance walked, VO2 Max, resting heart rate, blood pressure than Group B at P < 0.05. Conclusion: The study concluded that 18 months of lifestyle modifications are effective in improving the submaximal exercise tolerance in overweight school going children. Government policy makers and school authorities should take extreme steps to encourage physical activity

Keywords: Active lifestyle, lifestyle modifications, nutritional guidelines, overweight, submaximal exercise tolerance test, VO2max



How to cite this URL:
Malarvizhi D, Pasupathy S. Long Term Lifestyle Modifications on Submaximal Exercise Tolerance Test in Overweight Children, Tamil Nadu, India. Int J Nutr Pharmacol Neurol Dis [Epub ahead of print] [cited 2023 Feb 6]. Available from: https://www.ijnpnd.com/preprintarticle.asp?id=364632




   Introduction Top


The ability of the body to maintain continuous rhythmical exercise is referred to as cardio-vascular endurance. Apart from genetic endowment,[1] environmental, exercise, nutritional, hormonal, and neural factors, cardio-vascular endurance is also influenced by I VO2max, which is the individual’s maximum oxygen consumption rate during exercise; (i) VO2max, which allows a person to perform aerobic exercise to the maximum extent; (ii) oxygen consumption during exercise as measured by VO2max. As a result, aerobic performance is impaired, (ii) peak oxygen uptake during voluntary exercise is measured by pulmonary VO2 kinetics, (iii) lung VO2 kinetics is an indication of overall lung conditioning through a delicate balance between various mechanisms regulating oxygen delivery (Presentation Theory) and oxygen utilization (Utilization Theory), and (iv) muscle endurance is determined by the ability to maintain metabolically active state during timed exercise tests. (iv) Economy of movement measured in terms of delta efficiency, and VO2max and performance VO2max (percent VO2 measured over a longer period of time) are combined in percent VO2 at lactate threshold.[2],[3],[4],[5],[6],[7],[8] The aim of the study is to evaluate the life style changes over a year on submaximal exercise tolerance test in overweight children.


   Methodology Top


The study design was randomized control trial used to examine the impact of a school-based lifestyle modifications intervention on overweight and health outcomes among school children for a period of one and a half years between December 2019 and September 2021. The Institution’s ethical committee approved the protocol after it was presented to its members. A registration number for CTRI REF/2019/12/030080 was issued under reference number 1428/IEC/2018 dated 23/08/2018. Two high schools in Chengalpattu District, South India, selected for the study, 140 overweight children randomly recruited from 1300 healthy children. Participants in the study were presented with a talk explaining the study’s purpose and benefits before recruitment. The school authorities approved the study before begin. In each school where participants were recruited, a health talk explained the purpose of the study. The parents and students filled out a questionnaire, and informed consent was sought.

Inclusion criteria

Participants in the study had an average BMI of 85 to 95 percentiles for their age and sex range, and they had to be 11 to 15 years old. A brief description of the study purpose was provided to selected children. A pre-evaluation was conducted on all participants.

Exclusion criteria

A questionnaire was used to identify children with cardio-respiratory issues, such as asthma, bronchiectasis, congenital heart defects, and hypertension, as well as those with exercise conditions (such as neuromuscular disorders and musculoskeletal disorders), hospitalization within the past 3 months, a common cold within the previous 4 weeks, and those who were already doing exercises to control their weight. The study excluded all children who had one or more of the above conditions.

Confidence interval

Two sided: 99% power: 90% ratio of sample size (Group B/Group A): 1. The effect size formula used a large number of 1.19 for BMI z-scores over 6 months, based on a significant mean difference of *0.25 and standard deviation of 0.21. Taking a 30% drop-out rate into account, the sample size necessary to guarantee 80% predictive power would be 70 overweight children per subject group. Based on the mean difference between the two groups, calculations were made.

Parents and caregivers of overweight children were sent a letter recommending participation in the study after the screening took place at schools. During the phone call, parents were also briefed on the study. Parent/caregiver recruitment appointments were scheduled for those who expressed interest in participating. When the consent form was signed by the parent/caregiver, the appointment was scheduled, assent form was filled by the overweight children. Seventy three overweight children from first school was Group A Experimental group and 72 overweight children from second school was Group B Control group. Five children were dropped from the study because they have taken transfer from the school. So the post test was taken for 70 children in both the groups.

Several children were pre-evaluated and discussed in brief the study. The outcome measures were Anthropometric parameters and cardiovascular endurance. After the pretest evaluation Group A was treated with Lifestyle modifications, that is, scheduled physical activity [Table 1], nutritional modifications, and active life style methods and nutritional advice pamphlet was issued. Group B was treated with only a health education talk to parents and overweight children and nutritional advice pamphlet was issued. The posttest measurements were planned to take by 1 year of completion of intervention but because of Covid lockdown and schools were closed, it was taken after, 1 year 6 months. After the posttest evaluation Group B was trained with same exercise protocol and other interventions of Group A.
Table 1 Demographic details

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Assessment protocol

I. Dimensions of the human body

Anthropometric parameters, weight − weighing machine, height − stadio meter, BMI − body weight (kg)/height (m2), waist circumference − iliac crest and lower side of rib cage, circumference of the hips − widest portion of the buttocks − parallel your tape to the floor, waist hips ratio − ratio between waist circumference and hip circumference were measured. A calibrated measuring tape mounted on a wall was used to measure the height of the child. Weighing records were taken to the nearest 1 g. Based on the formula BMI = weight (kg)/height (m2), BMI was calculated.

II. Cardio vascular endurance assessment

6 minute walk test

The 6MWT used a corridor with color-coded tape marking 100-foot intervals (ATS Guidelines) as part of a standardized test protocol.[9],[10] In their briefing, the subjects were informed that the purpose of the test was to see how far they could walk in 6 minutes. It was instructed that they should walk up and down the corridor as many times as they could for 6 minutes.

The subject could rest at any time during the test if he or she desired. Subjects were urged not to engage in vigorous exercise for 2 hours before testing, but were advised to eat a light meal beforehand. Prior to testing, there was no "warm up" period allowed, and the subject was required to sit in a chair near the starting point for 10 minutes before beginning. An oxygen saturation meter and digital sphygmomanometer were used to measure resting pulse and blood pressure. An investigator used an electronic timer and counted laps for the 6MWT. Encouragements were consistently used during the examination.

The same person instructed each of the participants at set times during the test (“Keep going,” “The test is going well,” etc.). The distance covered by each participant in meters over the duration of the test was recorded (6MWD). Immediately after the test and after the recovery period of 3 and 5 minutes, pulse, blood pressure, and dyspnea (Borg scale)[11],[12] were measured.

Below is the formula used to calculate VO2 max. It is calculated by multiplying 12.701 with 0.06 times the 6-minute walk distance m − (0.732 times the body mass index kg/m2) (R2 = 0.79, standard error of the estimate [SEE] = 2.91 mL/kg/min, %SEE = 6.9%).


   Exercise intervention Top


During the demonstration, the instructor discussed how participant’s muscles would be stronger and their energy would be consumed more efficiently as a result of movement. Balance between resistance and aerobic exercise − moderate to vigorous exercise − 60 minutes. We have weekly fun activities (Fun Fridays), lasting an hour. Before starting the intervention with exercises, 3 weeks familiarization and flexibility exercises were done. The exercises were taught in a gradual manner like simple to complex exercises. Every third week, subjects were added with new exercise as per the protocol and repetitions also increased [Figure 1].
Figure 1 Exercise intervention.

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   Life style interventions Top


The following lifestyle modifications were advised to do with parents and children in both groups. Active play − inside and outside home, expose physical activity, at least once per week, arrange family physical activities. Walk or ride a bicycle to school or the store, use stairs for climbing up of buildings, Children − Home activities. Reduce time for watching television and playing computer games, watch television physically active for at least 1 hour and advised not to keep television and computer games inside the bedrooms.


   Nutritional guidelines Top


Parents/caregivers and children were provided nutritional guidance by a dietitian. As part of the program, participants completed an aerobics session designed to boost motivation levels and increase their desire to be more active, while a hands-on activity was designed to increase their understanding of how to prepare healthy food. The following nutritional guidelines were given to parents and children in both groups. Encourage to drink minimum 2 L of water, variety of foods, whole grains and cereals, meat and protein, fruits and vegetables, dairy, and fats. Advised to take preferably home-prepared food. Always take food rich in fiber, avoid high fat foods, oil, and ghee, minimize the use of high-sugar foods, and reduce the use of fat during food preparation. Do not consume sugary drinks with added sugar, avoid snacks/food made up of maida. Eat mealtimes and snack periods only, eat family meals, healthy breakfast and avoid skipping meals. Advised to take healthy snacks like fruits, carrots, and other vegetables attractive and readily available. Advices to parents like, healthy lunch box to school. Sufficient food should be kept without wasting in plates, not encourage food as a reward, sufficient calories, and all essential nutrients for growth. Focus should be given on healthy eating because the intervention period was long and the food should be tasty and allow different kind of foods, variety of colored food. Chocolates and biscuits intake should be reduced.[11]

Control group

Participant nutrition was assessed and their nutritional status was discussed, then dietary advice and physical activity recommendations were provided. There was no specific advice about how many cups of food to consume; only that fats and sweetened drinks were to be reduced, fruits and vegetables were to be consumed more, and physical activity was to be increased. Only a related brochure on nutritional guidelines was issued.


   Results Top


A total of 140 participants were involved in the study of which 30.0% were boys and 70.0 % were girls in the experimental Group A and 44.3% girls and boys 55.7 girls dominated the Group B. Among children 12 years old which is 18.60% in the experimental Group A and 32.9% in the control Group B, whereas 13 years old children which is 47.1% in the experimental Group A and 32.9% in the control Group B, whereas 14 years old children which is 34.3% in the experimental Group A and 34.3% in the control Group B.

[Table 2] shows the pre-test and post-test values are expressed in mean ± standard deviation. The result shows no significant difference between pre-test Group A (Experimental) & Group B (Control); whereas post-test shows significant difference between Group A (Experimental) and Group B (Control).
Table 2 Demographic details

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   Demographic details according to dimensions of the human body Top


The pretest and posttest results are presented in [Table 3]. Values are expressed in mean ± standard deviation; t-values and significant P values of Group A.
Table 3 Comparison of 6MWT between Group A and Group B

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The result shows no significant difference between pre-test Group A (Experimental) and Group B (Control); whereas post-test shows significant difference between Group A (Experimental) and Group B (Control). The results show post-test results significantly different from pre-test results above parameters mean indicators for Group A (Experimental) at P < 0.05 [Figure 2].
Figure 2 Comparison of 6MWT between Group A and Group B.

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The result shows no pre-test scores differ significantly from post-test scores Group B and testing after test Group B (Management); whereas Members A showed significant difference between Group A and post-test Group A (Experimental). The results show significant difference between pre and post-test above parameters mean values of Group A (Experimental) at P < 0.05. This is clearly indicated that experimental post-test-Group A showed significantly increased height, SPO2, rest HR whereas significantly decreased weight, BMI, rest heart rate, heart rate for 3 minutes, heart rate for 5 minutes, systolic blood pressure, and diastolic blood pressure of the children due to regular flexibility exercises, resistance, and aerobic exercise with healthy diet for 11 months.

[Table 4] shows the values before and after testing are expressed in mean ± standard deviation; t-values and significant P values of Group A; C.I.: Confidence Interval. The result shows no Pre-test and post-test differences are significant Both Groups A and B were experimental; whereas post-test shows significant difference between Group A (Experimental) and Group B (Control). The results show Post-test scores significantly different from pre-test scores. Distance walked mean values of Group A (Experimental) at P < 0.05.
Table 4 Comparison of distance walked between two groups: A and B

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According to [Table 3] and [Table 4] and [Figure 3], the result shows no pre-test and post-test differences are significant Group B and following the test Group B (Manage); whereas Organization A showed significant difference between Group A and post-test Group A (Experimental). The results shows post-test results significantly different from pre-test results distance walked mean A group’s values A (Experimental) at P < 0.05.
Figure 3 Comparison of distance walked between Group A and Group B.

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This is clearly indicated that experimental Post-test-Group A showed significantly increased distance walked of the children due to regular flexibility exercises, resistance, and aerobic exercise with healthy diet for 11 months.

[Table 5] shows results from the pre- and post-tests are shown below expressed in mean ± standard deviation; t-values and significant P values of Group A.
Table 5 Comparison of VO2 MAX between Group A and Group B

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The result shows no significant difference between pre-test Group A (Experimental) and Group B (Control); whereas post-test shows significant difference between Group A (Experimental) and Group B (Control). The results shows post-test results significantly different from pre-test results above parameters mean A group’s values A (Experimental) at P < 0.05.

According to [Table 5] and [Figure 4], the result shows no shows Results from the pre- and post-tests are shown below significant Group B and following the test Group B (Management); whereas Members A showed significant difference between Group A and post-test Group A (Experimental). The results shows significant difference between pre and post-test Maximal oxygen consumption mean values of Group A (Experimental) at P < 0.05.
Figure 4 Comparison of VO2 MAX between Group A and Group B.

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This is clearly indicated that experimental Post-test-Group A showed significantly increased Maximal oxygen consumption of the children due to regular flexibility exercises, resistance, and aerobic exercise with healthy diet for 11 months.


   Discussion Top


It has been shown that the 6-minute walk test (6MWT) is a safe, easy, and economical training technique highly acceptable intervention in this observational intervention study. Functional exercise capacity can be measured very simply and inexpensively by this method, even in young children, and this could prove useful when conducting similar studies. The 6MWT is proven to be effective is a useful prognostic indicator for functional capacity and is also a safe, reliable, and valid test in terms of its reliability. Evidence suggests the 6MWT has various advantages. This method is safe, reliable, and valid, and it can be utilized to assess functional capacity it can be used in both health and in health care settings.[12]

It has been demonstrated that both boys and girls can tolerate the 6MWT well and that the test can be used to determine individual body composition and expected effects of weight loss. Post-test Group A experienced weight and BMI reductions that were significantly greater than those of post-test Group B. The SPO2, SBP (P *0.01), and DBP of Group A post-test compared to Group A, they were significantly higher B. Comparison of distance walked among Group A and Group B (post-test) was greater than comparison of distance walked among Group A and B (pre-test). The 6MWT of obese women is increased regardless of weight loss by both aerobic and resistance training, according to a previous study. Accordingly, weight loss is predicted to increase 6MWT in men more than in women, reinstating the relation in normal-weight subjects. 6MWT is a test that assesses walking capacity and physical performance; overweight individuals have no difficulty completing the 6MWT test. Testing overweight subjects and their response to physical activity after a weight loss may prove useful in clinical settings for evaluating their response to weight loss.

It has been observed that, this study largely corroborates previous studies normative data on transportation behavior from Turkey,[13] Saudi Arabia,[14] Brazil,[15] while the shortest distances were measured in United Kingdom,[16] United States,[17] and Tunis. There are several factors that may be responsible for the great range in 6MWT findings in previous studies: (1) different age groups (4–17 years old[16],[18]); (2) sex distributions (girls and boys vs. only girls and boys[19]; (3) convenience samples without calculations; (4) corridor distances of 15 to 20 m[17]; and (5) requiring that the test be performed once or twice, at intervals of 15, 30, or 60 minutes.[19],[15]

A few studies have investigated the interaction between physiological and biomechanical variables, such as the heart rate, blood pressure, oxygen saturation, and the distance covered over 6 minutes.[18] There is a need to be cautious when interpreting previous normative data.

Studies have shown that walking distances vary widely,[20] therefore Normative values should be determined by each country walking distance, taking into account sociodemographic and anthropometric factors. Health-related professionals and physical educators can use the newly developed data for assessing. The ability to evaluate functional exercise capacity and identify those at risk of poor performance in order to design policies and interventions that optimize their performance can be implemented aimed at improving the functional performance of students. Predicting the expected performance during the test as well as the improvement in walking distance can be done based on easily obtainable clinical data prior to and following weight loss intervention. Among the metabolically at-risk overweight students, the metabolically healthy group A performed better during the walking distance, but experimental group A had a comparable response to the intervention when the walking distance was increased. Experimental Post-test-Group A showed significantly increased distance walked of the children due to regular flexibility exercises, resistance, and aerobic exercise with healthy diet for 11 months.

Cardio respiratory fitness is generally measured by maximum oxygen uptake (VO2 max).[21] Further, even though VO2 max has a large genetic component, it is strongly affected by the subject’s activity level, thereby serving also as a measure of activity level.[22] In research projects, VO2 max measurements have become routine in determining a subject’s cardiovascular capacity. The low levels of physical and vascular fitness that have been associated with cardio metabolic risk and overweight are correlated with lower levels of cardio respiratory fitness[23] as well as high body fatness, and a lack of cardio respiratory fitness in children Obesity’s negative effects may be related to inflammation. This is clearly indicated that experimental Post-test-Group A showed significantly increased maximal oxygen consumption of the children due to regular flexibility exercises, resistance, and aerobic exercise with healthy diet for 18 months.

The physical activity provides an essential stimulus for most organs of the human body, to develop and maintain their structures and functions meeting the general requirements of life. Chronic physical inactivity leads to dysfunction of health, while physical activity helps to increase or improve organ function. Geiger et al. have discussed about daily exercise and its summation effect to enhance immune defence activity and metabolic health.[24]

The aerobic exercise improves oxygen transport and increase in trained muscles capacity to mobilize and oxidize fat. It also produces metabolic adaptation in the different types of muscle fibers. Cardiovascular and respiratory systems were interlinked with both functional and dimensional systems such as heart rate, stroke volume, cardiac output, and blood flow and distribution. It also enhances the respiratory functions which alters performance and body composition changes. During exercise the cardiac output is diverted to the working muscle. There is increase in blood flow during exercise and also increase in cardiac output.

The ideal combination is diet plus exercise which offers more flexibility in fat loss than either exercise or diet alone and also achieving negative caloric balance. Children normally need certain number of calories each day that they use as energy for their daily activities such as walking, breathing and it ranges from 2000 calories for 7 to 10 years children. If a child consumes excess food and calories than those excess calories are converted into fat in overweight and obese children. The high intensity circuit training exercise burns the fat in less time. In terms of reducing the body fat, however when combining diet and exercise was most effective approach to weight loss.


   Conclusion Top


The study concluded that 18 months of lifestyle modifications are effective in improving the submaximal exercise tolerance in overweight school going children. In order to increase a child’s physical fitness, academic capability, and contribute to societal advancement, physical exercise and healthy food habits are fundamental. In addition to improving their health and decreasing their risks of lifestyle diseases, investing in physical fitness programs and children’s fitness can also help them to improve their self-esteem and academic achievement. Government policy makers and school authorities should take extreme steps to encourage physical activity and stopping of junk foods at least inside school campus and active environment like pathway for cycling. Since obesity and overweight are alarming the world all should take active participation in controlling.

Acknowledgements

The author acknowledges the subjects who participated in the study, the parents, physical educators, and school authorities who helped in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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