One small step for man…?
2004; Elsevier BV; Volume: 145; Issue: 6 Linguagem: Inglês
10.1016/j.jpeds.2004.08.053
ISSN1097-6833
Autores Tópico(s)Diabetes, Cardiovascular Risks, and Lipoproteins
ResumoResearchers interested in the physiology of fat should be thankful. The obesity epidemic has created the impetus for substantial basic and clinical work, and this work is increasingly before the public. The recent dramatic increase in the prevalence of insulin resistance and its feared consequence, type II diabetes mellitus, has allowed the understanding and documentation, in childhood, of a malignant progression from the accumulation of excess adiposity to the presence of target organ injury and disease morbidity. The journey encompasses the development of cardiovascular risk, sleep and other respiratory disorders, orthopedic abnormalities, the discovery that fat is an active metabolic tissue, new hormones (leptin and adponectin), the association with chronic low grade inflammation, psychosocial morbidity, and the demonstration of microvascular disease.1.Gidding S.S. Leibel R.L. Daniels S. Rosenbaum M. Van Horn L. Marx G.R. Understanding obesity in youth.Circulation. 1996; 94: 3383-3387Crossref PubMed Google ScholarIn this issue of The Journal, Kelly et al have, in a small controlled study, linked this new metabolic milieu of obesity to, surprise, exercise and physical fitness.2.Kelly A.S. Wetzsteon R.J. Kaiser D.R. Steinberger J. Bank A.J. Dengel D.R. Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise.J Pediatr. 2004; 145: 731-736Abstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar In those participating in a modest 8-week regular exercise program, statistically significant improvements in fitness, HDL cholesterol, and vascular function were observed. For most other variables studied, exercise was associated with trends in a favorable direction, although statistical significance was not achieved.This study is an example of the “one small step.” There is now developing, in many “small step” studies conducted in all age groups, a substantial body of work suggesting that sustained regular exercise over a lifetime is critical for health maintenance. Observations in much larger adult studies conducted with 15 or more years of follow-up provide “the giant leap for mankind.” Regular exercise and physical fitness prevent the development of hypertension, diabetes mellitus, and the metabolic syndrome; are more effective than pharmacologic therapy in preventing future diabetes mellitus; and, independent of the aforementioned risk factors, lower cardiovascular mortality by as much as 50%.3.Carnethon M.R. Gidding S.S. Nehgme R. Sidney S. Jacobs D.R. Liu K. Low physical fitness in young adulthood predicts the development of cardiovascular disease risk factors: the CARDIA study.JAMA. 2003; 290: 3092-3100Crossref PubMed Scopus (466) Google Scholar, 4.Knowler W.C. Barrett-Connor E. Fowler S.E. Hamman R.F. Larchin J.M. Walker E.A. et al.Reduction in the incidence of type 2 diabetes mellitus with lifestyle intervention or metformin.N Engl J Med. 2002; 346: 393-403Crossref PubMed Scopus (14324) Google Scholar, 5.Katzmarzyk P.T. Church T.S. Blair S.N. Cardiorespiratory fitness attenuates the effects of the metabolic syndrome on all-cause and cardiovascular disease mortality in men.Ach Intern Med. 2004; 164: 1092-1097Crossref PubMed Scopus (328) Google Scholar, 6.Gulati M. Pandey D.K. Arnsdorf M.F. Lauderdale D.S. Thisted R.A. Wicklund R.H. et al.Exercise capacity and the risk of death in women: the St James Women Take Heart Project.Circulation. 2003; 108: 1554-1559Crossref PubMed Scopus (544) Google Scholar Most of the small step studies show the benefit from exercise in one or two areas associated with the toxic milieu of obesity and insulin resistance. Well-conducted long-term clinical trials and epidemiologic observations show that these small steps are cumulative over time, that is, the long-term benefits of sustained exercise and activity are a giant leap toward sustained health. Because severely overweight persons are often both unfit and insulin resistant, they may benefit the most from increased regular exercise.2.Kelly A.S. Wetzsteon R.J. Kaiser D.R. Steinberger J. Bank A.J. Dengel D.R. Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise.J Pediatr. 2004; 145: 731-736Abstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar, 3.Carnethon M.R. Gidding S.S. Nehgme R. Sidney S. Jacobs D.R. Liu K. Low physical fitness in young adulthood predicts the development of cardiovascular disease risk factors: the CARDIA study.JAMA. 2003; 290: 3092-3100Crossref PubMed Scopus (466) Google Scholar, 4.Knowler W.C. Barrett-Connor E. Fowler S.E. Hamman R.F. Larchin J.M. Walker E.A. et al.Reduction in the incidence of type 2 diabetes mellitus with lifestyle intervention or metformin.N Engl J Med. 2002; 346: 393-403Crossref PubMed Scopus (14324) Google Scholar, 5.Katzmarzyk P.T. Church T.S. Blair S.N. Cardiorespiratory fitness attenuates the effects of the metabolic syndrome on all-cause and cardiovascular disease mortality in men.Ach Intern Med. 2004; 164: 1092-1097Crossref PubMed Scopus (328) Google Scholar, 6.Gulati M. Pandey D.K. Arnsdorf M.F. Lauderdale D.S. Thisted R.A. Wicklund R.H. et al.Exercise capacity and the risk of death in women: the St James Women Take Heart Project.Circulation. 2003; 108: 1554-1559Crossref PubMed Scopus (544) Google Scholar, 7.Gidding S.S. Nehgme R. Heise C. Muscar C. Linton A. Hassink S. Severe obesity associated with cardiovascular deconditioning, high prevalence of cardiovascular risk factors, diabetes mellitus/hyperinsulinemia, and respiratory compromise.J Pediatr. 2004; 144: 766-769Abstract Full Text Full Text PDF PubMed Scopus (90) Google ScholarThere are two important components to the work of Kelly et al and other researchers who have undertaken the difficult task of getting a group of overweight persons to change their lifestyles and to exercise. The first is the research that demonstrates scientifically that exercise is healthful; the second is the exercise itself. It is common in editorials to applaud the scientific work done by creative investigators and call for more research to enhance our understanding of the disease process under consideration. However, I would prefer to call for more of the second part of the study. I think we ought to do more exercise and exercise teaching than research.One hour per day of moderate-intensity work will expend about 300 kcal of energy or about 2000 calories per week, enough to help maintain body weight and improve insulin sensitivity.8.US Department of Health and Human Services Physical activity and health: a report of the surgeon general. National Center for Chronic Disease Prevention and Health Promotion, Washington, DC1996Google Scholar That hour must be scheduled into the daily grind. How do you know you have done enough? You can use a treadmill or other exercise machine and count calories or you can simply recognize that you have worked up a light sweat. You can walk 3 miles, ride a mountain bike 10 to 12 miles, march in a band, garden, swim laps, or dance. And, you can limit participation in sedentary activities such as television watching.9.American Academy of Pediatrics.Children, adolescents, and television. Pediatrics 107: 423-6.Google ScholarIt is too easy to get caught up in the excitement of the science. In 1969, when man first set foot on the moon and the people of the United States were gazing up at the sky, on the earth the Viet Nam war was being fought and the streets of US cities were tinder boxes. In obesity research, we try to find the pathologic mechanism. Is it endothelial injury? Is it insulin resistance secondary to low-grade vascular inflammation? If I am overweight but my C reactive protein is normal, have I dodged the “obesity bullet”? While looking up at the science we are missing what is happening on the ground: we eat too much, are too sedentary, and do not go out and play. Researchers interested in the physiology of fat should be thankful. The obesity epidemic has created the impetus for substantial basic and clinical work, and this work is increasingly before the public. The recent dramatic increase in the prevalence of insulin resistance and its feared consequence, type II diabetes mellitus, has allowed the understanding and documentation, in childhood, of a malignant progression from the accumulation of excess adiposity to the presence of target organ injury and disease morbidity. The journey encompasses the development of cardiovascular risk, sleep and other respiratory disorders, orthopedic abnormalities, the discovery that fat is an active metabolic tissue, new hormones (leptin and adponectin), the association with chronic low grade inflammation, psychosocial morbidity, and the demonstration of microvascular disease.1.Gidding S.S. Leibel R.L. Daniels S. Rosenbaum M. Van Horn L. Marx G.R. Understanding obesity in youth.Circulation. 1996; 94: 3383-3387Crossref PubMed Google Scholar In this issue of The Journal, Kelly et al have, in a small controlled study, linked this new metabolic milieu of obesity to, surprise, exercise and physical fitness.2.Kelly A.S. Wetzsteon R.J. Kaiser D.R. Steinberger J. Bank A.J. Dengel D.R. Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise.J Pediatr. 2004; 145: 731-736Abstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar In those participating in a modest 8-week regular exercise program, statistically significant improvements in fitness, HDL cholesterol, and vascular function were observed. For most other variables studied, exercise was associated with trends in a favorable direction, although statistical significance was not achieved. This study is an example of the “one small step.” There is now developing, in many “small step” studies conducted in all age groups, a substantial body of work suggesting that sustained regular exercise over a lifetime is critical for health maintenance. Observations in much larger adult studies conducted with 15 or more years of follow-up provide “the giant leap for mankind.” Regular exercise and physical fitness prevent the development of hypertension, diabetes mellitus, and the metabolic syndrome; are more effective than pharmacologic therapy in preventing future diabetes mellitus; and, independent of the aforementioned risk factors, lower cardiovascular mortality by as much as 50%.3.Carnethon M.R. Gidding S.S. Nehgme R. Sidney S. Jacobs D.R. Liu K. Low physical fitness in young adulthood predicts the development of cardiovascular disease risk factors: the CARDIA study.JAMA. 2003; 290: 3092-3100Crossref PubMed Scopus (466) Google Scholar, 4.Knowler W.C. Barrett-Connor E. Fowler S.E. Hamman R.F. Larchin J.M. Walker E.A. et al.Reduction in the incidence of type 2 diabetes mellitus with lifestyle intervention or metformin.N Engl J Med. 2002; 346: 393-403Crossref PubMed Scopus (14324) Google Scholar, 5.Katzmarzyk P.T. Church T.S. Blair S.N. Cardiorespiratory fitness attenuates the effects of the metabolic syndrome on all-cause and cardiovascular disease mortality in men.Ach Intern Med. 2004; 164: 1092-1097Crossref PubMed Scopus (328) Google Scholar, 6.Gulati M. Pandey D.K. Arnsdorf M.F. Lauderdale D.S. Thisted R.A. Wicklund R.H. et al.Exercise capacity and the risk of death in women: the St James Women Take Heart Project.Circulation. 2003; 108: 1554-1559Crossref PubMed Scopus (544) Google Scholar Most of the small step studies show the benefit from exercise in one or two areas associated with the toxic milieu of obesity and insulin resistance. Well-conducted long-term clinical trials and epidemiologic observations show that these small steps are cumulative over time, that is, the long-term benefits of sustained exercise and activity are a giant leap toward sustained health. Because severely overweight persons are often both unfit and insulin resistant, they may benefit the most from increased regular exercise.2.Kelly A.S. Wetzsteon R.J. Kaiser D.R. Steinberger J. Bank A.J. Dengel D.R. Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise.J Pediatr. 2004; 145: 731-736Abstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar, 3.Carnethon M.R. Gidding S.S. Nehgme R. Sidney S. Jacobs D.R. Liu K. Low physical fitness in young adulthood predicts the development of cardiovascular disease risk factors: the CARDIA study.JAMA. 2003; 290: 3092-3100Crossref PubMed Scopus (466) Google Scholar, 4.Knowler W.C. Barrett-Connor E. Fowler S.E. Hamman R.F. Larchin J.M. Walker E.A. et al.Reduction in the incidence of type 2 diabetes mellitus with lifestyle intervention or metformin.N Engl J Med. 2002; 346: 393-403Crossref PubMed Scopus (14324) Google Scholar, 5.Katzmarzyk P.T. Church T.S. Blair S.N. Cardiorespiratory fitness attenuates the effects of the metabolic syndrome on all-cause and cardiovascular disease mortality in men.Ach Intern Med. 2004; 164: 1092-1097Crossref PubMed Scopus (328) Google Scholar, 6.Gulati M. Pandey D.K. Arnsdorf M.F. Lauderdale D.S. Thisted R.A. Wicklund R.H. et al.Exercise capacity and the risk of death in women: the St James Women Take Heart Project.Circulation. 2003; 108: 1554-1559Crossref PubMed Scopus (544) Google Scholar, 7.Gidding S.S. Nehgme R. Heise C. Muscar C. Linton A. Hassink S. Severe obesity associated with cardiovascular deconditioning, high prevalence of cardiovascular risk factors, diabetes mellitus/hyperinsulinemia, and respiratory compromise.J Pediatr. 2004; 144: 766-769Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar There are two important components to the work of Kelly et al and other researchers who have undertaken the difficult task of getting a group of overweight persons to change their lifestyles and to exercise. The first is the research that demonstrates scientifically that exercise is healthful; the second is the exercise itself. It is common in editorials to applaud the scientific work done by creative investigators and call for more research to enhance our understanding of the disease process under consideration. However, I would prefer to call for more of the second part of the study. I think we ought to do more exercise and exercise teaching than research. One hour per day of moderate-intensity work will expend about 300 kcal of energy or about 2000 calories per week, enough to help maintain body weight and improve insulin sensitivity.8.US Department of Health and Human Services Physical activity and health: a report of the surgeon general. National Center for Chronic Disease Prevention and Health Promotion, Washington, DC1996Google Scholar That hour must be scheduled into the daily grind. How do you know you have done enough? You can use a treadmill or other exercise machine and count calories or you can simply recognize that you have worked up a light sweat. You can walk 3 miles, ride a mountain bike 10 to 12 miles, march in a band, garden, swim laps, or dance. And, you can limit participation in sedentary activities such as television watching.9.American Academy of Pediatrics.Children, adolescents, and television. Pediatrics 107: 423-6.Google Scholar It is too easy to get caught up in the excitement of the science. In 1969, when man first set foot on the moon and the people of the United States were gazing up at the sky, on the earth the Viet Nam war was being fought and the streets of US cities were tinder boxes. In obesity research, we try to find the pathologic mechanism. Is it endothelial injury? Is it insulin resistance secondary to low-grade vascular inflammation? If I am overweight but my C reactive protein is normal, have I dodged the “obesity bullet”? While looking up at the science we are missing what is happening on the ground: we eat too much, are too sedentary, and do not go out and play. Inflammation, insulin, and endothelial function in overweight children and adolescents: The role of exerciseThe Journal of PediatricsVol. 145Issue 6PreviewTo assess subclinical inflammation, fasting insulin, and endothelial function before and after exercise in overweight children and adolescents. Full-Text PDF
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