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Safe and
Effective
Exercise for
Overweight
Youth
Melinda S. Sothern
Boca Raton London New York
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DEDICATION
This book is dedicated to Dr. Charles Brown my “partner in crime,” or so he calls me. Charlie,
as he likes to be called, was instrumental in the integration of nutrition and exercise science
into medical school education. His efforts were vital to raising the awareness of physicians
nationwide to the importance of healthy nutrition and regular exercise to the prevention
and management of chronic diseases, such as obesity and related comorbidities, especially
in youth.
Charlie first began integrating his concepts for nutrition and exercise into professional sports
as the New Orleans Saints team physician internist, where he served from 1967 to 2000. In
1988, he helped write the newly formed “Drugs of Abuse and Alcohol Policy” for the National
Football League. Charlie then served as a member of this committee until his resignation in
2009. He was also a hero in the fight against smoking in public places. Charlie served as the
chairman of the Steering Committee of the Louisiana Cancer Research Center Tobacco Free
Living Initiative. Under his guidance, the state of Louisiana passed the Clean Indoor Air Act,
which prohibits smoking in public buildings and restaurants.
Charlie joined the Louisiana State University Health Sciences Center (LSUHSC) as a faculty
member in 1998 while I was conducting research in the Department of Pediatrics. I already
knew Charlie because he was the oncologist for one of my family members who survived
melanoma under his care. It was during this time that he and I discussed our similar phi-
losophies and passion for nutrition and exercise science, and collaborated on my very first
research abstract.
After Charlie joined the LSUHSC faculty, he and I worked together for more than a decade to
bring the dream of a research and educational wellness center to the university. I am pleased
to share that we now have a premier exercise and wellness facility at the LSUHSC, which
serves the medical students, faculty, staff, and their families. More important, the center
serves as a health promotion education resource to all while also providing state-of-the-art
exercise instruction to members and research study participants. Trained and experienced
staff members are available to help with the implementation of research studies examining
the benefits of nutrition and exercise to the prevention of obesity and related comorbidities.
Charlie also led the efforts to establish the Jim Finks Endowed Chair in Health Promotion,
which provides research funding for students and graduate assistants, and helps to support
the development of new projects for junior faculty. The availability of these resources has
made it possible for us to conduct innovative translational research in the social, behavioral,
environmental, biological, and molecular factors related to metabolic and inflammatory
disease and to study the impact of exercise and nutrition on this process in children and
adolescents.
The expansive reach of Charlie’s efforts over the years cannot be measured. His dedication
and passion for disease prevention through health promotion nationally and, especially in
the state of Louisiana, resulted in major initiatives to improve public health through policy,
research, and education. I am so grateful to be his colleague and partner, but more important
to call Charlie my friend.
CONTENTS
Preface xiii
Acknowledgments xvii
About the Author xix
Chapter 1 PROFILE OF THE OVERWEIGHT CHILD:
IMPLICATIONS FOR EXERCISE PRESCRIPTION
Factors That Limit Physical Activity in Children 2
Age and Stage of Development: Do Children Respond Differently than Adults? 2
Excess Adiposity: Is Exercise More Difficult in Overweight Children? 7
Responses of the Obese Child to Exercise 11
Aerobic Performance 13
Energy Cost of Movement 14
Muscular Strength and Endurance 14
Gross Motor Competence and Fundamental Movement Skills 15
Psychological Considerations 15
Implications to Exercise Prescription 16
Appropriate Exercise for Overweight and Obese Children 16
Inappropriate Exercise for Overweight and Obese Children 17
Summary 17
References 18
Chapter 2 AEROBIC EXERCISE
Defining Cardiorespiratory Endurance 28
Health Benefits of Aerobic Exercise in the Prevention and Management of Obesity
and Related Comorbidities in Youth 28
Prescribing Aerobic Exercise to Overweight and Obese Youth 32
Dancing 32
Interactive Computer Games 33
Aerobic Exercise: Intensity, Duration, and Frequency 34
Sample Class 36
Lesson 2, Level 1: Warming Up, Cooling Down, and the Metabolic Engines of the
Body 36
References 42
Chapter 3 STRENGTH (RESISTANCE) TRAINING
Muscular Strength and Endurance 49
Overload Principle 54
Periodization Training 55
Benefits of Strength Training in Youth 56
Developing Strength Training Programs for Youth 59
Number of Sets 61
Velocity—Speed of Movement 61
Load: Amount of Resistance, Number of Repetitions per Set 61
Adapting Strength Training to Overweight and Obese Children 63
Strength Training Guidelines 66
Strength Training Instructions and Illustrations 69
Pre-Set Warm-Up 70
Post-Set Stretch 70
Leg Extension, Sitting 70
Leg Curl, Standing 71
Rowing, Low 72
Overhead Press 73
Sitting Bicep Curl 74
Tricep Extension 75
Pelvic Tilt 76
Chest Press 76
Lower Back 77
Stomach Crunches 77
Squat, Standing 78
Standing Calves 79
Sample Class 82
Lesson 4, Level 1: Moderate-Intensity Progressive Exercise Program (MPEP)
Pump—Muscular Strength and Endurance Exercises 83
References 87
Chapter 4 FLEXIBILITY TRAINING
Flexibility and Stretching Activities 92
Benefits of Flexibility Training 94
Modifying Flexibility Exercise for Overweight and Obese Children 95
Flexibility Training in Overweight Children with Bone and Joint Problems 96
Flexibility Training Program: Instructions and Illustrations 96
Shoulder Stretch 97
Chest Stretch 98
Upper Back Stretch 99
Single Rear-Shoulder Stretch 100
Lying Quad Stretch 101
Seated Hamstring Stretch 102
Relax Your Back 102
Modified Butterfly Stretch 103
Butterfly Stretch 104
Straddle Stretch 105
Flex at Your Desk 105
Sample Class 108
Lesson 6, Level 1: Flexibility—The Body’s Balancing Act and the Flex Test 108
References 116
viii Contents
Chapter 5 MOTIVATING OVERWEIGHT CHILDREN TO
INCREASE PHYSICAL ACTIVITY
Determinants to Physical Activity 120
Motivational Theories and Models for Encouraging Positive Behavior
Change 123
Theory of Planned Behavior 123
Transtheoretical Model of Behavior Change 123
Self-Determination Theory 124
Social Cognitive Theory 124
Motivational Interviewing 127
Motivational Techniques and Strategies to Increase Physical Activity
in Overweight Youth 127
Initial Evaluation 127
Use of Music as a Motivational Tool 129
Team (Group) versus Individual Physical Activity 129
Individualizing Physical Activity Programs 130
Application of Social Cognitive Theory to Promote Physical Activity in
Multidisciplinary Settings 130
Putting Research into Practice: Lesson Plans Tailored to Overweight and
Obese Youth Using the Social Cognitive Theory 131
Increasing Daily Energy Expenditures: The Moderate-Intensity Progressive
Exercise Program 131
Body Movement Awareness: Muscular Strength and Endurance—The MPEP
Pump! 132
Summary 134
References 135
Chapter 6 PUTTING IT ALL TOGETHER
Tailoring Exercise to Individual Needs 142
Recommendations for Obese Youth with Hypertension 143
Recommendations for Obese Youth with Asthma 144
Recommendations for Obese Youth with Type 2 Diabetes 146
Recommendations for Children with Obesity-Related Musculoskeletal
Problems 148
Tailoring Exercise Recommendations to Age, Overweight Level, and
Associated Medical Problems 149
Clinical Overview of a Typical Multicomponent Weight Management
Program for Overweight Children 166
Program Overview 167
Family Intervention 168
Four-Level Progression 168
Managing Two Groups (New and Continuing Students) Simultaneously 175
40-Week Exercise Curriculum for Group, Family, Clinical,
and Home-Based Exercise Instruction 177
Putting Research into Practice: Weekly Exercise Lesson Plans
Tailored to Overweight and Obese Youth 179
Contents ix
Lesson 1, Level 1 (Red) 179
Lesson 2, Level 1 183
Lesson 3, Level 1 188
Lesson 4, Level 1 191
Lesson 5, Level 1 195
Lesson 6, Level 1 197
Lesson 7, Level 1 202
Lesson 8, Level 1 206
Lesson 9, Level 1 207
Lesson 10, Level 1 208
Lesson 1, Level 2 (Yellow) 210
Lesson 2, Level 2 212
Lesson 3, Level 2 214
Lesson 4, Level 2 214
Lesson 5, Level 2 216
Lesson 6, Level 2 218
Lesson 7, Level 2 220
Lesson 8, Level 2 221
Lesson 9, Level 2 223
Lesson 10, Level 2 223
Lesson 1, Level 3 (Green) 224
Lesson 2, Level 3 226
Lesson 3, Level 3 227
Lesson 4, Level 3 230
Lesson 5, Level 3 234
Lesson 6, Level 3 235
Lesson 7, Level 3 236
Lesson 8, Level 3 238
Lesson 9, Level 3 239
Lesson 10, Level 3 240
Lesson 1, Level 4 (Blue) 241
Lesson 2, Level 4 243
Lesson 3, Level 4 243
Lesson 4, Level 4 244
Lesson 5, Level 4 246
Lesson 6, Level 4 247
Lesson 7, Level 4 248
Lesson 8, Level 4 248
Lesson 9, Level 4 249
Lesson 10, Level 4 249
References 251
Chapter 7 MONITORING PROGRESS
Importance of Regular Medical Self-Monitoring 262
Tracking Obesity in Children 262
Performing the Initial Medical Evaluation 264
Ordering and Interpreting Laboratory Blood Work 264
Providing Ongoing Medical Supervision 264
x Contents
Monitoring Patient Progress 265
Evaluating Long-Term Progress 269
Growth and Development 270
Body Mass Index and CDC Percentiles 270
Waist Circumference 270
Blood Pressure and Heart Rate 271
Laboratory Blood Work 271
Body Composition Analysis: Estimate of the Percentage of Body Fat 271
Physical Activity Level 272
Physical Fitness 273
References 278
Chapter 8 MEASURING HEALTH AND FITNESS OUTCOMES
Appropriate and Reliable Protocols for Measuring Outcomes 286
Anthropometrics and Body Composition 286
Measurement of Height 286
Measurement of Weight 286
Weight Status and Estimate of Body Composition 286
Circumference Measurements 288
Skinfold Analysis 290
Bioelectrical Impedance 291
Measurement of Differential Photon Absorption Using Dual-Energy X-Ray
Absorptiometry 292
Central Adiposity: Abdominal (Visceral) Fat 292
Ectopic Fat in Skeletal Muscle and Liver Using Proton Magnetic Resonance
Spectroscopy 292
Measurement of Resting Blood Pressure 293
Measurement of Resting Heart Rate 293
Laboratory Blood Work 293
Blood Collection and Processing 294
Chemistry and Lipid Measures 294
Measures of Physical Activity Level and Fitness 294
Measurement of Physical Activity by Accelerometer 294
System for Observing Fitness Instruction Time 295
SOFIT Observer Training, Assessment, and Recalibration 296
Metabolic Equivalent to Determine Exercise Intensity and Energy Expenditure 297
Physical Activity Self-Report Questionnaires 297
Fundamental Movement Skill Competency 300
Detailed Exercise Testing Protocols: Measurement of Fitness 300
Cycle Ergometry Fitness Testing 301
Loftin–Sothern Test 301
Field Testing of Cardiorespiratory (Aerobic) Endurance 302
Muscular Strength and Endurance Testing 302
Muscular Flexibility Testing 303
Measurement of Resting Metabolism: Resting Energy Expenditure and
Respiratory Quotient 303
Contents xi
Tanner Staging 304
References 304
Chapter 9 WHAT TO EXPECT
Metabolic Health Outcomes after Physical Activity and Exercise Training 312
Exercise Training and Fat Oxidation 313
Cognitive, Emotional, and Physical Health Outcomes of Regular Physical Activity 314
Biochemical, Anthropometric, Behavioral, and Fitness Outcomes Related
to Physical Activity 315
Current U.S. Evidence-Based Recommendations for Physical Activity 316
Evidence-Based Recommendations for Physical Activity in School-Age Youth 316
Recommendations for Outdoor Play 317
Evidence-Based Recommendations for Physical Activity: Physically Inactive
School-Age Youth 318
Summary of Evidence-Based Studies Including Exercise in Overweight Children 318
Lifestyle Recommendations by Weight Classification 318
References 320
Chapter 10 FUTURE TRENDS IN EXERCISE RESEARCH IN
OVERWEIGHT AND OBESE YOUTH
Primary Targets for Exercise Research in Overweight and Obese Children 328
School Environment 329
Before-, During, and After-School Opportunities 330
Community and Recreational Settings: The Built Environment 332
Family and Home Environment 332
Factors That Inhibit Exercise in Overweight and Obese Youth 333
Evaluating Exercise Outcomes: Weight Bias and Developmental Issues 334
Summary 336
References 336
Index 341
xii Contents
PREFACE
This textbook, Safe and Effective Exercise for Overweight Youth, encompasses decades of sci-
entific research and clinical experience. The recommendations contained within are based
on current scientific evidence and my personal clinical experience working with thousands
of overweight and obese children and adolescents for 24 years. The contents provide accurate,
scientifically sound, and practical guidance that clinical health care providers, educators,
public health, and fitness professionals may utilize to promote physical activity in overweight
and obese children of all ages, including those with significant obesity and chronic health
conditions, such as hypertension, asthma, and type 2 diabetes. The text also provides a cur-
rent best practices model for implementing clinical- and recreational-based physical activity
interventions for preventing and managing pediatric obesity based on decades of research
experience by leaders in the field. In addition, this text complements the Handbook of
Pediatric Obesity: Clinical Management, which I coedited along with psychologist T. Kristian
von Almen, PhD, and pediatrician Stewart Gordon, MD, and was published in 2006.
In preparation for writing this book, I spent 2 years gathering information in an effort to
update the tailored exercise prescriptions contained within, which were designed specifically
to age, level of obesity, and medical condition. I discovered in this process that the origi-
nal exercise guidelines that I developed in collaboration with Dr. Mark Loftin, and which
were based on physiologic and metabolic testing in his laboratory at the University of New
Orleans, are still applicable today. In this regard, the scientific evidence actually followed our
initial exercise testing findings and resulting intervention design, as our early observational
studies were repeated and conducted in more rigorous scientific designs by other research-
ers. The results of these subsequent studies continually supported our initial hypothesis:
Children with increasing levels of obesity are physiologically and metabolically impaired dur-
ing exercise, especially weight-bearing modalities. This is especially relevant in younger chil-
dren with comorbidities such as asthma, insulin resistance, and type 2 diabetes, and even
more pertinent in those with musculoskeletal problems or disorders. As such, the results of
our exploratory research became the conduit for future more rigorous scientific studies that
now support current U.S. guidelines for physical activity in overweight and obese youth.
In the initial exercise curriculum, which was designed based on the results of our research,
we established two major goals for managing overweight conditions in children: (1) increas-
ing overall energy expenditure by raising daily activity levels and improving body movement
awareness through fitness counseling, including motivational techniques based on social
cognitive theory (Bandura, 1986); and (2) improving cardiopulmonary endurance, muscular
strength, and flexibility by engaging in a structured and tailored moderate-intensity, pro-
gressive exercise program. The first goal was accomplished by motivating the child to replace
sedentary behavior with short bursts of light to moderate activities, such as twisting while
watching television, dancing to a favorite song, shooting hoops outside, riding a bike to a
friend’s house, or stretching on the floor throughout the day while educating him or her on
how the body responds to movement. Children thus gained the physiologic and kinesthetic
awareness necessary to adopt physical activity patterns that promote long-term health. This
goal was intended to be promoted in parallel with the second goal. The second goal was
accomplished by establishing weekly short-term goals for intensity, duration, and frequency
based on information from our laboratory findings, which provided upper level limits of
ability for each obesity category, that is, level 1 (red) severely obese (more than 20 percent
of the 95th percentile BMI or an absolute BMI greater than 35 kg/m2 [Kelly et al., 2013;
U.S. Centers for Disease Control and Prevention, 2012]), level 2 (yellow) obese (more than
95th–99th percentile BMI), level 3 (green) overweight (more than 85th–95th percentile
BMI), and level 4 (blue) healthy weight or maintenance (less than 85th percentile BMI).
Children were encouraged to select activities that they enjoyed from a list of options with
an intensity and modality (weight-bearing or non-weight-bearing activities) appropriate for
their individual overweight level. Goals for how long and often they should exercise became
more challenging as they progressed through the program. These recommendations eventu-
ally were utilized to develop an individualized exercise program, which was translated for
home use in the book, Trim Kids: The Proven 12-Week Plan That Has Helped Thousands of
Children Achieve a Healthier Weight (2001) with coauthors T. Kristian von Almen, PhD, and
Heidi Schumacher, RD.
Our original recommendations remain appropriate for healthy weight, overweight, obese,
and severely obese youth with and without comorbidities. Current research, however, indi-
cates that light activity, in particular, including activities that require the body weight to be
supported (weight-bearing activities) are advantageous for improving metabolic health in
overweight and obese children. In a recent review of decades of research (see Chapter 10), it
was concluded that exercise prescriptions in overweight and obese youth should consider a
multistep strategy. In this case, sedentary activities initially are replaced with light activities
that are enjoyable and unstructured, such as table tennis, billiards, darts, archery, fishing, or
playing in a pool. Then intensity gradually is increased over time by selecting moderate and
then vigorous activities in such a way that U.S. guideline goals to include 60 minutes of mod-
erate- to vigorous-intensity activity eventually are met. Thus, the original goal of increasing
overall energy expenditure by raising daily activity levels is now more specific as the recom-
mendations in this text also include options for light-intensity activities, which are specific
to age, obesity level, and medical condition, during the first few weeks of the program. Light
to moderate exercise is supported by a multitude of researchers as overweight and obese
children can exercise at this intensity for long periods without fatigue, thus enabling youth
to burn calories and fat (see Chapters 1 and 10). This, in turn, improves metabolic health,
promotes the attainment of a healthy body weight, and reduces the risk of developing obesity
comorbidities.
HOW TO USE THIS BOOK
Chapters 1–5 provide an overview of the existing scientific literature in support of individu-
alized, tailored exercise prescriptions for overweight and obese children with and without
comorbidities. This information provides the basis of support for the specific recommenda-
tions contained in Chapters 6–9. Chapters 2–5 also contain exercise instructions, illustra-
tions, and sample lesson plans to improve cardiopulmonary endurance, muscular strength,
power and endurance, and muscular flexibility.
Chapter 6 applies the existing scientific literature to specific guidelines for prescribing exer-
cise to overweight children along with verbal cues or “talking points,” clinical reminders,
and handouts to assist health care providers with discussing the most appropriate exercise
modality, intensity, frequency, and duration for each child’s individual needs. At the end of
the chapter, a 40-week exercise curriculum, including lesson plans, is provided, which can
be implemented in clinical, recreational, or home-based settings. This curriculum contains
the complete exercise intervention from the comprehensive, multidisciplinary approach that
my colleagues and I utilized successfully for more than two decades to assist children in
achieving a healthier weight. Our hands-on, clinical setting provided the optimal laboratory
in which to discover what is unique about obese children and to identify specific approaches
and activities for promoting improved health through increased physical activity and struc-
tured exercise.
xiv Preface
Chapter 7 discusses the importance of regular medical and self-monitoring and also provides
easy tools and techniques that health care providers can use to track the child’s progress,
including forms, handouts, talking points, and reminders. Chapters 8 and 9 provide detailed
clinical and field protocols to assist with the measurement of health and fitness outcomes.
Chapter 9 also describes realistic expectations and presents the current U.S. recommenda-
tions for promoting physical activity and fitness in youth. Chapter 10 provides a summary
of current studies to support future research in the area of physical activity to prevent and
manage pediatric obesity.
Each chapter contains printable forms that can be used in clinical practice or community and
field settings. These forms also may be downloaded from our website at http://publichealth
.lsuhsc.edu. In addition, this website provides links to exercise instructional videos that
are based on the color-coded four-level approach, and a link to an educational series from
Louisiana Public Broadcasting Company as well as updates from our current studies, Trim
Teens and Trim Tots.
SUMMARY
Many professionals lack the time to keep up to date on such a rapidly changing field of pedi-
atric exercise science as it relates to the prevention and treatment of obesity and chronic
disease. Medical, public health, recreational, and exercise professionals need a solid, read-
ily available resource to consult when developing exercise plans for overweight and obese
children. More important, colleges, universities, and medical schools need an authoritative
manual on the subject of childhood obesity to better prepare health care and educational
professionals on the appropriate care and counseling of physical activity and exercise for
obese youth. Safe and Effective Exercise for Overweight Youth provides a state-of-the-art,
scientifically supported, and clinically relevant source of information to research, medical,
educational, public health, and recreational professionals, which is essential to the design
of appropriate exercise interventions for obese youth. The text condenses all of the avail-
able s cientific literature and recommendations into a prescriptive, comprehensive guide and
hopefully will serve as a valued resource to universities, hospitals, recreational and educa-
tional facilities, clinics, and physician offices.
The success or failure of children to achieve a healthy weight is a responsibility that is shared
by both the family and the health care professional. This textbook will provide the necessary
information and tools for you to become proficient in matching or tailoring physical activ-
ity recommendations to the medical, physical, and emotional needs of developing children.
When paired with your dedication, positive approach, time, and energy, the most appropri-
ate care can be provided to overweight and obese children and adolescents.
REFERENCES
Bandura, A. (1986). Social Foundations of Thoughts and Actions: A Social Cognitive Theory.
Englewood Cliffs, NJ: Prentice-Hall.
Kelly, A. S., Barlow, S. E., Rao, G., Inge, T. H., Hayman, L. L., Steinberger, J., et al. (2013). Severe
obesity in children and adolescents: Identification, associated health risks, and treatment
approaches—A scientific statement from the American Heart Association. Circulation,
128(15), 1689–1712.
Preface xv
Sothern, M., Gordon, S., von Almen, T. K. (Eds.). (2006). Handbook of Pediatric Obesity:
Clinical Management. Boca Raton, FL: Taylor & Francis.
Sothern, M., von Almen, T. K., Schumacher, H. (2001). Trim Kids: The Proven Plan That Has
Helped Thousands of Children Achieve a Healthier Weight. New York, NY: HarperCollins.
U.S. Centers for Disease Control and Prevention. (2012). Overweight and obesity:
Consequences. Retrieved June 9, 2012, from http://www.cdc.gov/obesity/childhood/
basics.html.
xvi Preface
