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Review |

Impact of Dietary and Exercise Interventions on Weight Change and Metabolic Outcomes in Obese Children and Adolescents:  A Systematic Review and Meta-analysis of Randomized Trials FREE

Mandy Ho, MSc, BHs, APD, RN1,3; Sarah P. Garnett, PhD, M Nutr&Diet, BSc, RNutr, APD1,2,3; Louise A. Baur, MBBS, BSc, PhD, FRACP2,3; Tracy Burrows, PhD, BHs, AdvAPD4; Laura Stewart, PhD, BSc, BA, RD, RNutr5,6; Melinda Neve, PhD, BND, APD4; Clare Collins, PhD, BSc, Dip Nutr&Diet, Dip Clin Epi, FDAA4
[+] Author Affiliations
1Institute of Endocrinology and Diabetes, The Children’s Hospital at Westmead, Sydney, Australia
2Kids Research Institute, The Children’s Hospital at Westmead, Sydney, Australia
3The Children’s Hospital at Westmead Clinical School, University of Sydney, Sydney, Australia
4Priority Research Centre in Physical Activity and Nutrition, School of Health Sciences, Faculty of Health, University of Newcastle, Newcastle, Australia
5Paediatric Overweight Service Tayside, Perth Royal Infirmary, Perth, Scotland
6The Children’s Weight Clinic, Edinburgh, Scotland
JAMA Pediatr. 2013;167(8):759-768. doi:10.1001/jamapediatrics.2013.1453.
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Published online

Importance  Diet and exercise represent the mainstays of obesity treatment. No systematic review has been conducted comparing the effect of dietary and exercise intervention in reducing metabolic risks in overweight children.

Objective  To compare the effects of diet-only intervention with those of diet plus exercise or exercise only on weight loss and metabolic risk reduction in overweight children.

Evidence Review  English-language articles from 1975 to 2010 available from 7 databases were reviewed. One person searched the databases. Two independent reviewers assessed abstracts and articles against the following eligibility criteria: randomized controlled trials conducted in overweight and obese children aged 18 years or younger, comparing dietary intervention with a diet plus exercise program or an exercise-only program. Study quality was critically appraised by 2 reviewers using established criteria. The main outcome measures were body mass index, body fat percentage, lean body mass, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, fasting glucose, and fasting insulin.

Findings  Fifteen studies were identified and included. Based on the small number of short-term trials currently available, both diet-only and diet plus exercise interventions resulted in weight loss and metabolic profile improvement. However, the addition of exercise to dietary intervention led to greater improvements in levels of high-density lipoprotein cholesterol (3.86 mg/dL [to convert to millimoles per liter, multiply by 0.0259]; 95% CI, 2.70 to 4.63), fasting glucose (−2.16 mg/dL [to convert to millimoles per liter, multiply by 0.0555]; 95% CI, −3.78 to −0.72), and fasting insulin (−2.75 μIU/mL [to convert to picomoles per liter, multiply by 6.945]; 95% CI, −4.50 to −1.00) over 6 months. The diet-only intervention caused greater reductions in levels of triglycerides (at the end of active intervention) and low-density lipoprotein cholesterol (at subsequent follow-up).

Conclusions and Relevance  This review provides insights into the impact of dietary and exercise interventions on metabolic risk reduction in the pediatric population. However, further studies are required to confirm the evidence with rigorous design, appropriate sample size, longer duration of follow-up, and better strategies to improve compliance and achieve long-term sustainability.

Figures in this Article

Obesity in children and adolescents is a major public health problem, with high or increasing prevalence reported in many countries.1,2 Diet and exercise represent the mainstays of obesity treatment.3,4 Several systematic reviews of the treatment of childhood obesity have found positive effects of interventions that include a dietary or exercise component.58 However, these reviews did not assess the effect of diet or exercise separately—dietary interventions were evaluated as adjuncts to exercise interventions, or vice versa. It is therefore unclear whether diet plus exercise or exercise only is more effective than a diet-only intervention for improving weight status in overweight and obese children and adolescents. It is also unclear how best to combine dietary and exercise interventions.

Childhood obesity is linked to a range of immediate and long-term health complications, including an increased risk of cardiovascular disease.3,912 To our knowledge, no systematic review has been conducted on the effects of dietary and exercise intervention in reducing metabolic risks in overweight and obese children. This review aimed to systematically assess the effects of diet-only interventions compared with diet plus exercise interventions on both weight loss and metabolic risk reduction. We also directly compared diet-only programs with exercise-only programs to examine the isolated effects of dietary modification and increased physical activity on weight loss and metabolic risks.

This review’s protocol is based on a peer-reviewed protocol registered with the Joanna Briggs Institute6 and covers English-language literature published between 1975 and 2010. The search strategy, exclusion criteria, details of study selection, quality assessment, and data extraction have been previously published.8 In brief, a medical librarian conducted the literature search. Two independent reviewers assessed abstracts and articles against eligibility criteria and critically appraised the methodological quality using established criteria (eAppendix in Supplement).

Eligibility Criteria

Eligible studies were randomized trials of treatment for overweight and obesity in children and adolescents aged 18 years or younger comparing the effectiveness of dietary intervention programs with that of diet plus exercise or an exercise-only intervention. To be included in this review, the studies had to report at least 1 anthropometric outcome. Programs that involved the entire family or were directed exclusively at parents of overweight or obese children and adolescents were also included.

Data Synthesis

Review Manager software version 5.1 (Cochrane Collaboration) was used for meta-analyses. Body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was the primary anthropometric outcome, and secondary outcomes were body fat percentage (%BF) and lean body mass (LBM). Metabolic outcomes were levels of low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, fasting glucose, and fasting insulin.

A weighted mean difference was calculated if the same measurement scale was used. When mean differences and associated standard deviations for anthropometric and metabolic outcomes were not published, they were estimated from the prevalues and postvalues based on methods from the Cochrane Handbook for Systematic Reviews of Interventions.13 A fixed-effect model was used for the meta-analyses as we hypothesized that the diet and exercise interventions were estimating 1 underlying effect. We performed meta-analyses among subgroups by exercise type (aerobic, resistance training, and a combination of both) when there were 2 or more studies in the subgroup. Heterogeneity was assessed by I2 statistics. Where outcomes could not be meta-analyzed, they are summarized narratively. Egger’s regression test and funnel plots were generated using Comprehensive Meta-analysis software version 2.2.064 (Biostat) to examine for publication bias if there were more than 10 studies for a given comparison. A significant statistical test (P < .05) or funnel plot asymmetry suggests potential publication bias.

Literature Search

The literature search identified 6023 references (Figure 1), and 763 full articles were retrieved. Twenty-three articles (15 different studies) met all inclusion criteria.1436 Fourteen studies compared diet-only intervention with diet plus exercise intervention18,19,2127,29,31,33,35,36 and 4 compared diet-only intervention with exercise-only intervention.20,23,25,26

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Figure 1.
Flowchart for Identification of Trials for Inclusion in the Systematic Review and Meta-analyses
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Description of Included Studies

Table 1 summarizes study characteristics. Five were conducted in the United States,21,22,27,29,33 2 in Australia,26,31 2 in Brazil,19,24 and 2 in Hong Kong.18,36 Eight recruited obese children exclusively20,21,2325,29,31,36; the rest targeted both overweight and obese children. Most (n = 9) were conducted in a hospital environment,1820,24,25,27,31,33,36 3 in the community,21,26,35 and 1 in a school.23 Most (n = 10) were in children (defined as aged ≤12 years),1821,2426,29,31,36 2 were in adolescents,22,23 and the rest enrolled both children and adolescents.27,33,35 Sample size ranged from 20 to 165, with a median of 38 participants per study. Intervention duration varied from 6 weeks to 6 months. About half (n = 7) followed up participants after the completion of active intervention18,20,21,25,26,29,35; however, only 1 study followed up participants longer than 1 year from baseline.29

Table Graphic Jump LocationTable 1.  Study Characteristics of Included Trials, Structured by Year of Publication
Methodological Quality

The study quality of included studies was generally suboptimal. Details of randomization,18,19,2224,27,29,31,33,35 allocation concealment,18,19,2125,27,29,31,33,35 and study blinding18,19,2125,27,29,31,33,35,36 were inadequately reported for most studies. Nearly half (n = 7) did not report dropout rate explicitly at all follow-up points.18,19,23,24,27,29,31 Retention rates for the remaining studies ranged from 42% to 100% at the latest point of follow-up (Table 1) and were similar for diet-only, exercise-only, and diet plus exercise intervention arms. A third (n = 5) used intention-to-treat analysis.18,25,26,33,36

Dietary Interventions

Most studies (n = 9) used a calorie restriction approach, with energy levels ranging from 900 to 1800 kcal/d and with varied macronutrient combinations18,19,2325,27,33,35,36 (Table 2). Others either used the Traffic Light Diet,29 aimed at limiting added sugar consumption and increasing dietary fiber intake,22 or provided general dietary advice. A dietitian was reported to be involved in the delivery of dietary interventions in 9 studies.1820,23,2527,33,36 The intensity of nutrition education interventions varied from a one-off 15-minute DVD session21 to 10 weekly 2-hour nutrition sessions plus monthly telephone follow-up for 3 months26 (Table 2). Seven studies measured compliance to dietary recommendations,18,19,23,25,27,29,36 with only 4 reporting these results18,23,29,36 (eTable 1 in Supplement).

Table Graphic Jump LocationTable 2.  Description of Interventions and Results of Main Weight-Related Outcomes, Structured by Year of Publication
Exercise Interventions

Thirteen studies conducted supervised training sessions, although the intensity and variety varied.1820,2227,31,33,35,36 Eight predominantly involved aerobic exercise1921,23,24,27,31,33 and 4 predominantly involved resistance training.18,22,35,36 Two investigated the effects of aerobic plus resistance training.22,25 One study targeting younger children (aged 5-9 years) provided a physical activity skills development program.26 All studies except one29 provided at least 70 minutes of exercise per week and 1 school-based program provided a total of 6 hours of indoor exercise per week23 (Table 2). Most did not mention who delivered exercise interventions. Only 4 measured and reported compliance to exercise training18,24,29,36 (eTable 1 in Supplement).

Comparing Diet-Only vs Diet Plus Exercise Intervention
Effects on Anthropometric Outcomes

Twelve of 14 studies reported a reduction in BMI and/or %BF over 6 months. Meta-analysis of the postintervention effects of 9 studies including 519 participants showed no significant differences in BMI between the diet-only and the diet plus aerobic subgroups (P = .21) or a combination of aerobic and resistance training subgroups (P = .59) (Figure 2). The diet-only group showed a greater BMI reduction than the diet plus resistance training group (pooled difference, −0.40; 95% CI, −0.71 to −0.08; I2 = 0%) over 4 months. In 3 studies reporting BMI outcomes at 1-year follow-up, BMI change was not significantly different between intervention groups (P = .67) (eFigure 1A in Supplement).

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Figure 2.
Meta-analysis of Studies Comparing Diet Plus Exercise and Diet-Only Interventions Using Change in Body Mass Index at the End of Active Intervention

CAST indicates aerobic and strength training; IV, inverse variance; and ST, strength training. Body mass index is calculated as weight in kilograms divided by height in meters squared.

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We examined effects of the intervention on body composition using 5 studies for which data on %BF or LBM were reported. Subgroup analysis showed that participants involved in 20 to 60 minutes of resistance training per week for 6 weeks achieved greater %BF loss than the diet-only group (pooled difference, −0.50%; 95% CI, −0.94 to −0.06; I2 = 0%) (eFigure 1B in Supplement). An opposite trend was observed in the diet plus aerobic training group, but the heterogeneity was high (I2 = 75%) and this finding needs to be interpreted with caution. Two studies followed up participants at 1 year from baseline: %BF loss was significantly greater in the diet plus exercise intervention group compared with the diet-only group (pooled difference, −2.73%; 95% CI, −4.38 to −1.09; I2 = 55%) (eFigure 1C in Supplement).

This result was consistent with the meta-analysis based on changes in LBM, which showed that diet plus resistance training led to greater muscle gain than the diet-only intervention (pooled difference, 0.44 kg; 95% CI, 0.04 to 0.84; I2 = 46%) over 4 months (eFigure 1D in Supplement).

There was no evidence of publication bias or small study effect with Egger’s test (P = .22) or visual inspection of the funnel plot for anthropometric outcomes (eFigure 2 in Supplement). Two studies were not included in meta-analyses because weight loss was reported as change in percentage overweight or sum of skin folds29,31 (Table 1 and Table 2).

Effects on Lipid Profile

Six studies reported blood lipid results18,19,2527,36 (eTable 2 in Supplement). All reported a reduction in BMI and/or %BF in both intervention groups after active intervention. The diet-only arm had a BMI loss of 0.5 to 3.0 and a %BF loss of 0.2% to 4.5%, while the diet plus exercise group had a BMI loss of 0.2 to 3.0 and a %BF loss of 0.7% to 3.5% over 6 months. In parallel, total cholesterol, LDL-C, and triglycerides levels were improved or maintained in both intervention groups. At the end of active intervention, the pooled difference in the triglycerides level was 13.27 mg/dL (to convert to millimoles per liter, multiply by 0.0113) in favor of the diet-only intervention (95% CI, −23.89 to −1.77; I2 = 0%; 376 participants) compared with diet plus exercise (Figure 3A). However, the diet plus exercise intervention showed a greater improvement in the HDL-C level (pooled difference, 3.86 mg/dL [to convert to millimoles per liter, multiply by 0.0259]; 95% CI, 2.70 to 4.63; I2 = 67%; 437 participants) (Figure 3B). These differences became nonsignificant at 1-year follow-up from baseline (eFigure 3, A and B in Supplement). Changes in the LDL-C level were the same for both intervention groups after active intervention (Figure 3C), and the pooled difference in the LDL-C level was 5.41 mg/dL (to convert to millimoles per liter, multiply by 0.0259) (95% CI, −9.27 to −1.16; I2 = 0%; 275 participants) in favor of the diet-only intervention at subsequent follow-up (eFigure 3C in Supplement).

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Figure 3.
Meta-analysis of Studies Comparing Diet Plus Exercise and Diet-Only Interventions, With Changes in Triglycerides (A), HDL-C (B), and LDL-C (C) at the End of Active Intervention as Outcomes

IV indicates inverse variance. To convert triglycerides from millimoles per liter to milligrams per deciliter, divide by 0.0113. To convert high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) from millimoles per liter to milligrams per deciliter, divide by 0.0259.

Graphic Jump Location
Effects on Fasting Glucose and Insulin Levels

Five studies reported fasting glucose and insulin results.19,22,25,26,32 One was excluded from the fasting insulin meta-analyses as the baseline readings were significantly higher in the diet-only group compared with the diet plus exercise group.19 Meta-analyses showed a greater improvement in the fasting glucose level (pooled difference, −2.16 mg/dL [to convert to millimoles per liter, multiply by 0.0555]; 95% CI, −3.78 to −0.72; I2 = 30%; 318 participants) and the fasting insulin level (pooled difference, −2.75 μIU/mL [to convert to picomoles per liter, multiply by 6.945]; 95% CI, −4.50 to −1.00; I2 = 0%; 279 participants) in the diet plus exercise group compared with the diet-only intervention after active intervention (Figure 4). However, the differences became nonsignificant at subsequent follow-up (eFigure 4 in Supplement).

Place holder to copy figure label and caption
Figure 4.
Meta-analysis of Studies Comparing Diet Plus Exercise and Diet-Only Interventions, With Changes in Fasting Glucose (A) and Fasting Insulin (B) at the End of Active Intervention as Outcomes

CAST indicates aerobic and strength training; IV, inverse variance; and ST, strength training. To convert glucose from millimoles per liter to milligrams per deciliter, divide by 0.0555. To convert fasting insulin from picomoles per liter to micro–international units per milliliter, divide by 6.945.

Graphic Jump Location
Comparing Diet-Only vs Exercise-Only Intervention
Effects on Anthropometric Outcomes

At the end of active intervention, all studies (n = 4) showed a reduction in BMI, BMI z score, waist circumference, or waist circumference z score in both treatment arms.20,23,25,26 Over 6 months, diet-only interventions had mean BMI reductions ranging from 0.8 to 2.7 and mean waist circumference reductions ranging from 1.1 to 3.8 cm. In the exercise-only group, mean BMI reductions ranged from 0.3 to 1.0 and mean waist circumference reductions ranged from 0.7 to 3.9 cm. Three studies followed up participants 6 to 9 months after active intervention.20,25,26 Only 1 study, conducted in younger children, showed that the BMI change was sustained at subsequent follow-up in the diet-only group in which nutrition education was provided to parents only.26 Meta-analysis was not conducted as the heterogeneity was high.

Effects on Metabolic Outcomes

Three studies reported results on blood lipids, fasting glucose, and fasting insulin20,25,26 (eTable 2 in Supplement). Shalitin et al25 compared the effect of a hypocaloric diet of 1200 kcal/d (55%-65% carbohydrate, 10%-15% protein, and 25%-30% fat) vs 90 minutes of moderate exercise (aerobic plus resistance training) 3 days/week in obese children aged between 6 and 11 years (Table 2). At 12 weeks, BMI, %BF, and blood lipids improved in both groups, and the diet-only group showed greater reductions in BMI (−1.1; 95% CI, −1.5 to −0.6) and LDL-C level (−7.72 mg/dL; 95% CI, −15.44 to −0.77) compared with the exercise-only group. Both groups regained weight after 9 months. The decreases in LDL-C and triglycerides levels in the diet-only group were preserved, while other metabolic outcomes regressed so that there were no group differences at 1-year follow-up (eTable 2 in Supplement).

Kelishadi et al20 compared a balanced diet (55% carbohydrate, 15% protein, and 30% fat) vs 40 minutes of aerobic exercise training 5 days/week. Participants of both groups had significant weight loss as well as reductions in total cholesterol and triglycerides levels after 6 months; however, they regained weight from the end of intervention to follow-up at 12 months from baseline, and blood lipids returned to baseline levels (eTable 2 in Supplement). Both studies reported no significant change in fasting glucose or insulin levels after active intervention or at subsequent follow-up.20,25

Okely et al26 compared a parent-centered dietary program with a child-centered physical activity program and found no group difference in the changes in metabolic profiles after a 6-month trial or at 1-year follow-up from baseline. Meta-analysis was not conducted as the heterogeneity was high.

To our knowledge, this is the first systematic review examining the effects of diet-only and diet plus exercise interventions on change in weight and metabolic risks in overweight and obese children and adolescents. Based on the small number of short-term randomized trials available, we found that diet plus resistance training led to a greater gain in LBM and reduction in %BF compared with diet alone. Some evidence of achieving greater improvement in HDL-C, fasting glucose, and fasting insulin levels by adding exercise training to dietary interventions was found, although diet-only intervention had a greater reduction in triglycerides levels immediately following intervention and a greater reduction in LDL-C levels 1 year from baseline.

Findings on BMI change are consistent with a review37 of the effects of resistance training on metabolic outcomes in children that found resistance training did not favorably affect BMI relative to no-treatment or diet-only controls. Our meta-analyses suggest that the observed increase in BMI in the diet plus exercise group, especially when resistance training was added, may be due to gain in LBM, which is beneficial for long-term weight loss. This reiterates that BMI is a less sensitive indicator of body composition and weight change in children and adolescents. Future dietary and exercise interventions should consider including other outcome measures of adiposity, such as %BF and LBM.

Subgroup analyses demonstrated that diet plus aerobic training resulted in significantly greater improvement in HDL-C levels compared with diet plus resistance training. This was consistent with others38 who showed that aerobic exercise resulted in a greater change in HDL-C levels in school-aged youths (including healthy and overweight participants) compared with resistance training. However, our meta-analyses showed that diet plus aerobic and resistance training in combination was superior to diet plus either modality alone in decreasing fasting glucose and insulin concentrations. This suggests that future lifestyle interventions should incorporate both aerobic and resistance training to achieve a better metabolic outcome.

The diet-only arm showed a greater reduction in levels of triglycerides (at the end of active intervention) and LDL-C (at 1-year follow-up) compared with diet plus exercise. Most studies did not provide information on adherence to dietary or exercise prescriptions or the actual dietary intake and physical activity levels, making it impossible to assess the impact of dietary compliance overall. Because levels of triglycerides and LDL-C are highly correlated with dietary intake,39 one possible explanation is that the diet plus exercise group received exercise training and regarded dietary intervention as a subsidiary part of the treatment, thus having lower adherence to the dietary prescriptions and reducing the intervention effect compared with the diet-only group. We recommend that future studies monitor and report intervention adherence as well as explore strategies to improve dietary and physical activity compliance.

The review showed that partial weight regain, and the subsequent regression in metabolic profiles to baseline levels, is common in the diet-only, exercise-only, and diet plus exercise intervention arms at subsequent follow-up times. Future diet and exercise studies should explore strategies to enhance effective weight maintenance following an initial intervention.

Concerns have been expressed that dietary restrictions used in obesity treatment may adversely decrease resting metabolic rate and muscle mass.40 This review found that an energy-restricted diet (900-1400 kcal/d) along with a moderate protein content (20%-30%) did not result in a loss of LBM in 6- to 18-years-olds over 4 months. Loss of LBM was reported in the diet plus exercise arm of a small study (n = 38) in which participants were prescribed an 1800-kcal diet with 65% total energy from carbohydrate and 15% from protein and were offered supervised exercise training 3 times per week (60 minutes/session).24 Participants lost 1.3 kg in LBM (95% CI, −2.01 to −0.59) over 4 months. However, adequately powered research is needed to confirm this and to explore the effect of varying the macronutrient distribution within dietary interventions in pediatric populations.

There were insufficient studies to allow direct comparison of the effects of diet-only vs exercise-only interventions. Diet-only interventions appeared to result in a greater BMI reduction in the short term compared with exercise-only arms. Without information on change in LBM, it is not possible to comment on whether this is because the exercise-only group was gaining LBM, the diet-only group was losing LBM, or both. It remains unclear whether diet-only or exercise-only interventions are more effective for reducing weight and metabolic risk in the pediatric population. Also, more trials are required to explore the effects of diet plus aerobic training and diet plus resistance training in this population.

Several limitations should be acknowledged. First, this review was confined to published literature, and publication bias cannot be excluded. Second, a high degree of clinical and statistical heterogeneity among the included studies means that the results should be interpreted with caution. Potential sources of heterogeneity include variations in the participant populations, the intensity and duration of interventions, and differences in the diet and exercise regimens. The review was also limited by suboptimal methodological quality of included studies and lack of information on intervention adherence. To facilitate future systematic reviews, authors should report intervention adherence and actual dietary intake and physical activity levels. Further limitations were the short duration of follow-up and the small sample size of many studies. Finally, without individual participant data, we were not able to determine to what extent the change in metabolic risk was associated with weight loss or whether participants with abnormal metabolic profiles obtained greater benefit from the intervention compared with those with normal profiles. Despite these limitations, this review included meta-analyses that improve the statistical power, provide more precise estimates, and resolve issues relating to the conflicting results among the small studies.

This review provides support for the importance of dietary interventions as an essential component for managing childhood obesity and provides insights into the impact of different exercise modalities on weight loss and metabolic risk reduction. Dietary interventions in conjunction with exercise interventions are effective in reducing metabolic risks, particularly HDL-C and fasting insulin levels, in overweight and obese children in the short term. Future studies should aim to strengthen the evidence with rigorous design, appropriate sample size, and longer follow-up periods and should explore better strategies to improve compliance and achieve long-term sustainability.

Corresponding Author: Mandy Ho, MSc, BHs, APD, RN, Institute of Endocrinology and Diabetes, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia (mandy.ho@sydney.edu.au).

Accepted for Publication: November 11, 2012.

Published Online: June 17, 2013. doi:10.1001/jamapediatrics.2013.1453.

Author Contributions:Study concept and design: Ho, Garnett, Baur, Stewart, Neve, and Collins.

Acquisition of data: Ho, Garnett, Burrows, Neve, and Collins.

Analysis and interpretation of data: Ho, Garnett, Baur, Burrows, Stewart, and Collins.

Drafting of the manuscript: Ho, Garnett, Burrows, and Stewart.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Ho and Burrows.

Administrative, technical, and material support: Ho, Burrows, Neve, and Collins.

Study supervision: Garnett, Baur, and Collins.

Conflict of Interest Disclosures: None reported.

Funding/Support: Ms Ho is supported by Dora Lush Postgraduate Research Scholarship APP 1017189 from the Australian National Health and Medical Research Council. Dr Garnett is supported by Early Career Development Fellowship Grant 10/ECF/2-11 from the Cancer Institute NSW. Dr Neve is supported by a postdoctoral fellowship from the Priority Research Centre in Physical Activity and Nutrition. Dr Collins is supported by a Career Development Fellowship from the Australian National Health and Medical Research Council. The 1975-2003 review received funding support from the Joanna Briggs Institute.

Additional Contributions: Debbie Booth, M App Sci (LIM), Faculty of Health, The University of Newcastle, assisted with the search and retrieve strategies and Megan Dunkley, BSc, Children’s Hospital at Westmead, read the manuscript and provided useful comments.

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Ribeiro  MM, Silva  AG, Santos  NS,  et al.  Diet and exercise training restore blood pressure and vasodilatory responses during physiological maneuvers in obese children. Circulation. 2005;111(15):1915-1923.
PubMed   |  Link to Article
Kelishadi  R, Hashemipour  M, Mohammadifard  N, Alikhassy  H, Adeli  K.  Short- and long-term relationships of serum ghrelin with changes in body composition and the metabolic syndrome in prepubescent obese children following two different weight loss programmes. Clin Endocrinol (Oxf). 2008;69(5):721-729.
PubMed   |  Link to Article
Leach  RA, Yates  JM.  Nutrition and youth soccer for childhood overweight: a pilot novel chiropractic health education intervention. J Manipulative Physiol Ther. 2008;31(6):434-441.
PubMed   |  Link to Article
Davis  JN, Tung  A, Chak  SS,  et al.  Aerobic and strength training reduces adiposity in overweight Latina adolescents. Med Sci Sports Exerc. 2009;41(7):1494-1503.
PubMed   |  Link to Article
Elloumi  M, Ben Ounis  O, Makni  E, Van Praagh  E, Tabka  Z, Lac  G.  Effect of individualized weight-loss programmes on adiponectin, leptin and resistin levels in obese adolescent boys. Acta Paediatr. 2009;98(9):1487-1493.
PubMed   |  Link to Article
Prado  DM, Silva  AG, Trombetta  IC,  et al.  Weight loss associated with exercise training restores ventilatory efficiency in obese children. Int J Sports Med. 2009;30(11):821-826.
PubMed   |  Link to Article
Shalitin  S, Ashkenazi-Hoffnung  L, Yackobovitch-Gavan  M,  et al.  Effects of a twelve-week randomized intervention of exercise and/or diet on weight loss and weight maintenance, and other metabolic parameters in obese preadolescent children. Horm Res. 2009;72(5):287-301.
PubMed   |  Link to Article
Okely  AD, Collins  CE, Morgan  PJ,  et al.  Multi-site randomized controlled trial of a child-centered physical activity program, a parent-centered dietary-modification program, or both in overweight children: the HIKCUPS study. J Pediatr. 2010;157(3):388-394, e1.
PubMed   |  Link to Article
Becque  MD, Katch  VL, Rocchini  AP, Marks  CR, Moorehead  C.  Coronary risk incidence of obese adolescents: reduction by exercise plus diet intervention. Pediatrics. 1988;81(5):605-612.
PubMed
Epstein  LH, McCurley  J, Wing  RR, Valoski  A.  Five-year follow-up of family-based behavioral treatments for childhood obesity. J Consult Clin Psychol. 1990;58(5):661-664.
PubMed   |  Link to Article
Epstein  LH, Valoski  A, Wing  RR, McCurley  J.  Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol. 1994;13(5):373-383.
PubMed   |  Link to Article
Epstein  LH, Wing  RR, Koeske  R, Valoski  A.  Effects of diet plus exercise on weight change in parents and children. J Consult Clin Psychol. 1984;52(3):429-437.
PubMed   |  Link to Article
Hills  AP, Parker  AW.  Obesity management via diet and exercise intervention. Child Care Health Dev. 1988;14(6):409-416.
PubMed   |  Link to Article
Rocchini  AP, Katch  V, Schork  A, Kelch  RP.  Insulin and blood pressure during weight loss in obese adolescents. Hypertension. 1987;10(3):267-273.
PubMed   |  Link to Article
Rocchini  AP, Katch  V, Anderson  J,  et al.  Blood pressure in obese adolescents: effect of weight loss. Pediatrics. 1988;82(1):16-23.
PubMed
Rocchini  AP, Katch  VL, Grekin  R, Moorehead  C, Anderson  J.  Role for aldosterone in blood pressure regulation of obese adolescents. Am J Cardiol. 1986;57(8):613-618.
PubMed   |  Link to Article
Schwingshandl  J, Sudi  K, Eibl  B, Wallner  S, Borkenstein  M.  Effect of an individualised training programme during weight reduction on body composition: a randomised trial. Arch Dis Child. 1999;81(5):426-428.
PubMed   |  Link to Article
Sung  RYT, Yu  CW, Chang  SKY, Mo  SW, Woo  KS, Lam  CWK.  Effects of dietary intervention and strength training on blood lipid level in obese children. Arch Dis Child. 2002;86(6):407-410.
PubMed   |  Link to Article
Benson  AC, Torode  ME, Fiatarone Singh  MA.  Effects of resistance training on metabolic fitness in children and adolescents: a systematic review. Obes Rev. 2008;9(1):43-66.
PubMed
Janssen  I, Leblanc  AG.  Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act. 2010;7(1):40.
PubMed   |  Link to Article
Daniels  SR, Pratt  CA, Hayman  LL.  Reduction of risk for cardiovascular disease in children and adolescents. Circulation. 2011;124(15):1673-1686.
PubMed   |  Link to Article
Gutin  B.  Diet vs exercise for the prevention of pediatric obesity: the role of exercise. Int J Obes (Lond). 2011;35(1):29-32.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Flowchart for Identification of Trials for Inclusion in the Systematic Review and Meta-analyses
Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Meta-analysis of Studies Comparing Diet Plus Exercise and Diet-Only Interventions Using Change in Body Mass Index at the End of Active Intervention

CAST indicates aerobic and strength training; IV, inverse variance; and ST, strength training. Body mass index is calculated as weight in kilograms divided by height in meters squared.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Meta-analysis of Studies Comparing Diet Plus Exercise and Diet-Only Interventions, With Changes in Triglycerides (A), HDL-C (B), and LDL-C (C) at the End of Active Intervention as Outcomes

IV indicates inverse variance. To convert triglycerides from millimoles per liter to milligrams per deciliter, divide by 0.0113. To convert high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) from millimoles per liter to milligrams per deciliter, divide by 0.0259.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.
Meta-analysis of Studies Comparing Diet Plus Exercise and Diet-Only Interventions, With Changes in Fasting Glucose (A) and Fasting Insulin (B) at the End of Active Intervention as Outcomes

CAST indicates aerobic and strength training; IV, inverse variance; and ST, strength training. To convert glucose from millimoles per liter to milligrams per deciliter, divide by 0.0555. To convert fasting insulin from picomoles per liter to micro–international units per milliliter, divide by 6.945.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Study Characteristics of Included Trials, Structured by Year of Publication
Table Graphic Jump LocationTable 2.  Description of Interventions and Results of Main Weight-Related Outcomes, Structured by Year of Publication

References

Wang  Y, Lobstein  T.  Worldwide trends in childhood overweight and obesity. Int J Pediatr Obes. 2006;1(1):11-25.
PubMed   |  Link to Article
de Onis  M, Blössner  M, Borghi  E.  Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr. 2010;92(5):1257-1264.
PubMed   |  Link to Article
Lobstein  T, Baur  L, Uauy  R; IASO International Obesity TaskForce.  Obesity in children and young people: a crisis in public health. Obes Rev. 2004;5(suppl 1):4-104.
PubMed   |  Link to Article
Hainer  V, Toplak  H, Mitrakou  A.  Treatment modalities of obesity: what fits whom? Diabetes Care. 2008;31(suppl 2):S269-S277.
PubMed   |  Link to Article
Collins  CE, Warren  J, Neve  M, McCoy  P, Stokes  BJ.  Measuring effectiveness of dietetic interventions in child obesity: a systematic review of randomized trials. Arch Pediatr Adolesc Med. 2006;160(9):906-922.
PubMed   |  Link to Article
Collins  CE, Warren  JM, Neve  M, McCoy  P, Stokes  B.  Systematic review of interventions in the management of overweight and obese children which include a dietary component. Int J Evid Based Healthc. 2007;5(1):2-53.
PubMed   |  Link to Article
Atlantis  E, Barnes  EH, Singh  MAF.  Efficacy of exercise for treating overweight in children and adolescents: a systematic review. Int J Obes (Lond). 2006;30(7):1027-1040.
PubMed   |  Link to Article
Ho  M, Garnett  SP, Baur  L,  et al.  Effectiveness of lifestyle interventions in child obesity: systematic review with meta-analysis. Pediatrics. 2012;130(6):e1647-e1671.
PubMed   |  Link to Article
Daniels  SR, Arnett  DK, Eckel  RH,  et al.  Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation. 2005;111(15):1999-2012.
PubMed   |  Link to Article
Steinberger  J, Daniels  SR, Eckel  RH,  et al; American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; and Council on Nutrition, Physical Activity, and Metabolism.  Progress and challenges in metabolic syndrome in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2009;119(4):628-647.
PubMed   |  Link to Article
Weiss  R. Cardiovascular risk clustering in obese children. In: Debasis  B, ed. Global Perspectives on Childhood Obesity. San Diego, CA: Academic Press; 2011:139-146.
Nadeau  KJ, Maahs  DM, Daniels  SR, Eckel  RH.  Childhood obesity and cardiovascular disease: links and prevention strategies. Nat Rev Cardiol. 2011;8(9):513-525.
PubMed   |  Link to Article
Higgins J, Greens S, eds. Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0 (updated March 2011). http://www.cochrane-handbook.org. Accessed January 2, 2011.
Yu  CCW, Sung  RYT, So  RCH,  et al.  Effects of strength training on body composition and bone mineral content in children who are obese. J Strength Cond Res. 2005;19(3):667-672.
PubMed
Burrows  T, Warren  JM, Baur  LA, Collins  CE.  Impact of a child obesity intervention on dietary intake and behaviors. Int J Obes (Lond). 2008;32(10):1481-1488.
PubMed   |  Link to Article
Yu  CCW, Sung  RYT, Hau  KT, Lam  PKW, Nelson  EAS, So  RCH.  The effect of diet and strength training on obese children’s physical self-concept. J Sports Med Phys Fitness. 2008;48(1):76-82.
PubMed
Burrows  T, Warren  JM, Collins  CE.  The impact of a child obesity treatment intervention on parent child-feeding practices. Int J Pediatr Obes. 2010;5(1):43-50.
PubMed   |  Link to Article
Woo  KS, Chook  P, Yu  CW,  et al.  Effects of diet and exercise on obesity-related vascular dysfunction in children. Circulation. 2004;109(16):1981-1986.
PubMed   |  Link to Article
Ribeiro  MM, Silva  AG, Santos  NS,  et al.  Diet and exercise training restore blood pressure and vasodilatory responses during physiological maneuvers in obese children. Circulation. 2005;111(15):1915-1923.
PubMed   |  Link to Article
Kelishadi  R, Hashemipour  M, Mohammadifard  N, Alikhassy  H, Adeli  K.  Short- and long-term relationships of serum ghrelin with changes in body composition and the metabolic syndrome in prepubescent obese children following two different weight loss programmes. Clin Endocrinol (Oxf). 2008;69(5):721-729.
PubMed   |  Link to Article
Leach  RA, Yates  JM.  Nutrition and youth soccer for childhood overweight: a pilot novel chiropractic health education intervention. J Manipulative Physiol Ther. 2008;31(6):434-441.
PubMed   |  Link to Article
Davis  JN, Tung  A, Chak  SS,  et al.  Aerobic and strength training reduces adiposity in overweight Latina adolescents. Med Sci Sports Exerc. 2009;41(7):1494-1503.
PubMed   |  Link to Article
Elloumi  M, Ben Ounis  O, Makni  E, Van Praagh  E, Tabka  Z, Lac  G.  Effect of individualized weight-loss programmes on adiponectin, leptin and resistin levels in obese adolescent boys. Acta Paediatr. 2009;98(9):1487-1493.
PubMed   |  Link to Article
Prado  DM, Silva  AG, Trombetta  IC,  et al.  Weight loss associated with exercise training restores ventilatory efficiency in obese children. Int J Sports Med. 2009;30(11):821-826.
PubMed   |  Link to Article
Shalitin  S, Ashkenazi-Hoffnung  L, Yackobovitch-Gavan  M,  et al.  Effects of a twelve-week randomized intervention of exercise and/or diet on weight loss and weight maintenance, and other metabolic parameters in obese preadolescent children. Horm Res. 2009;72(5):287-301.
PubMed   |  Link to Article
Okely  AD, Collins  CE, Morgan  PJ,  et al.  Multi-site randomized controlled trial of a child-centered physical activity program, a parent-centered dietary-modification program, or both in overweight children: the HIKCUPS study. J Pediatr. 2010;157(3):388-394, e1.
PubMed   |  Link to Article
Becque  MD, Katch  VL, Rocchini  AP, Marks  CR, Moorehead  C.  Coronary risk incidence of obese adolescents: reduction by exercise plus diet intervention. Pediatrics. 1988;81(5):605-612.
PubMed
Epstein  LH, McCurley  J, Wing  RR, Valoski  A.  Five-year follow-up of family-based behavioral treatments for childhood obesity. J Consult Clin Psychol. 1990;58(5):661-664.
PubMed   |  Link to Article
Epstein  LH, Valoski  A, Wing  RR, McCurley  J.  Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol. 1994;13(5):373-383.
PubMed   |  Link to Article
Epstein  LH, Wing  RR, Koeske  R, Valoski  A.  Effects of diet plus exercise on weight change in parents and children. J Consult Clin Psychol. 1984;52(3):429-437.
PubMed   |  Link to Article
Hills  AP, Parker  AW.  Obesity management via diet and exercise intervention. Child Care Health Dev. 1988;14(6):409-416.
PubMed   |  Link to Article
Rocchini  AP, Katch  V, Schork  A, Kelch  RP.  Insulin and blood pressure during weight loss in obese adolescents. Hypertension. 1987;10(3):267-273.
PubMed   |  Link to Article
Rocchini  AP, Katch  V, Anderson  J,  et al.  Blood pressure in obese adolescents: effect of weight loss. Pediatrics. 1988;82(1):16-23.
PubMed
Rocchini  AP, Katch  VL, Grekin  R, Moorehead  C, Anderson  J.  Role for aldosterone in blood pressure regulation of obese adolescents. Am J Cardiol. 1986;57(8):613-618.
PubMed   |  Link to Article
Schwingshandl  J, Sudi  K, Eibl  B, Wallner  S, Borkenstein  M.  Effect of an individualised training programme during weight reduction on body composition: a randomised trial. Arch Dis Child. 1999;81(5):426-428.
PubMed   |  Link to Article
Sung  RYT, Yu  CW, Chang  SKY, Mo  SW, Woo  KS, Lam  CWK.  Effects of dietary intervention and strength training on blood lipid level in obese children. Arch Dis Child. 2002;86(6):407-410.
PubMed   |  Link to Article
Benson  AC, Torode  ME, Fiatarone Singh  MA.  Effects of resistance training on metabolic fitness in children and adolescents: a systematic review. Obes Rev. 2008;9(1):43-66.
PubMed
Janssen  I, Leblanc  AG.  Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act. 2010;7(1):40.
PubMed   |  Link to Article
Daniels  SR, Pratt  CA, Hayman  LL.  Reduction of risk for cardiovascular disease in children and adolescents. Circulation. 2011;124(15):1673-1686.
PubMed   |  Link to Article
Gutin  B.  Diet vs exercise for the prevention of pediatric obesity: the role of exercise. Int J Obes (Lond). 2011;35(1):29-32.
PubMed   |  Link to Article

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Multimedia

Supplement.

eAppendix. Joanna Briggs Institute critical appraisal of study quality tool.

eFigure 1. Meta-analyses of studies comparing diet-plus-exercise interventions with diet-only. A, Outcome: Change in BMI(kg/m2) at 1 year follow up from baseline. B, Outcome: Change in body fat percentage at the end of active intervention. C, Outcome: Change in body fat percentage at 1 year follow up from baseline. D, Outcome: Change in lean body mass (kg) at the end of active intervention.

eFigure 2. Funnel plot of 12 studies (13 comparisons) comparing diet-plus-exercise interventions with diet-only program using anthropometric outcomes (BMI, body fat percentage and lean body mass).

eFigure 3. Meta-analyses of studies comparing diet-plus-exercise interventions with diet-only at 1 year follow up from baseline. A, Outcome: Change in triglycerides (mmol/L) at 1 year follow up from baseline. B, Outcome: Change in HDL-Cholesterol (mmol/L) at 1 year follow up from baseline. C, Outcome: Change in LDL-Cholesterol (mmol/L) at 1 year follow up from baseline.

eFigure 4. Meta-analyses of studies comparing diet-plus-exercise interventions with diet-only at 1 year follow up from baseline. A, Outcome: Change in fasting glucose (mmol/L) at 1 year follow up from baseline. B, Outcome: Change in fasting insulin (pmol/L) at 1 year follow up from baseline.

eTable 1. Measurement and report of intervention compliance.

eTable 2. Effects of dietary and exercise interventions on anthropometric and metabolic outcomes (structured by year of publication).

eReferences

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