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Article |

Inflammatory Proteins and Muscle Strength in Adolescents:  The AVENA Study FREE

Jonatan R. Ruiz, PhD; Francisco B. Ortega, PhD; Julia Wärnberg, PhD; Luis A. Moreno, MD, PhD; Juan J. Carrero, PhD; Marcela Gonzalez-Gross, PhD; Ascension Marcos, PhD; Angel Gutierrez, MD, PhD; Michael Sjöström, MD, PhD
[+] Author Affiliations

Author Affiliations: Unit for Preventive Nutrition, Department of Biosciences and Nutrition at Novum (Drs Ruiz, Ortega, Wärnberg, and Sjöström) and Division of Renal Medicine and Baxter Novum, Department of Clinical Science (Dr Carrero), Karolinska Institutet, Huddinge, Sweden; Department of Physiology, School of Medicine, University of Granada, Granada, Spain (Drs Ruiz, Ortega, and Gutierrez); Immunonutrition Research Group, Department of Metabolism and Nutrition, Consejo Superior de Investigaciones Científicas, Madrid, Spain (Drs Wärnberg and Marcos); Escuela Universitaria Health Sciences, University of Zaragoza, Zaragoza, Spain (Dr Moreno); and School of Sport Sciences, Universidad Politécnica de Madrid, Madrid, Spain (Dr Gonzalez-Gross).


Arch Pediatr Adolesc Med. 2008;162(5):462-468. doi:10.1001/archpedi.162.5.462.
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Objectives  To examine the associations between inflammatory proteins and muscle strength and to determine whether this association varies between overweight and nonoverweight adolescents.

Design  Cross-sectional study.

Participants  A total of 416 Spanish adolescents (230 boys and 186 girls) aged 13 to 18½ years.

Main Exposures  Muscle strength score was computed as the mean of the handgrip and standing broad jump standardized values. The adolescents were categorized as overweight (including obese) or nonoverweight according to body mass index. Body fat and fat-free mass were derived from skinfold thickness.

Outcome Measures  C-reactive protein, complement factors C3 and C4, ceruloplasmin, and prealbumin levels.

Results  The results of the regression analysis showed that C-reactive protein, C3, and ceruloplasmin were negatively associated with muscle strength after controlling for sex, age, pubertal status, weight, height, socioeconomic status, and cardiorespiratory fitness. Moreover, C-reactive protein and prealbumin levels were associated with muscle strength in overweight adolescents after controlling for potential confounders, including body fat and fat-free mass.

Conclusions  Low-grade inflammation is negatively associated with muscle strength in adolescents. The patterns of these associations seem more relevant in overweight adolescents, suggesting that having high levels of muscle strength may counteract the negative consequences ascribed to body fat.

Figures in this Article

Low-grade inflammation seems to play a role in the development of cardiovascular disease from an early age.1,2 It is negatively associated with cardiorespiratory fitness and positively associated with body fat in young people and adults.37 Recent findings have shown a higher prevalence of having high C-reactive protein levels in overweight and unfit Spanish adolescents compared with their overweight and fit counterparts.8 Inflammatory proteins have also been negatively associated with muscle strength in adults.911 The causal pathway leading from inflammation to loss of muscle strength has not been fully explained, but it has been suggested that low-grade inflammation may cause a decline of physical functioning through its catabolic effects on skeletal muscle.12

The role of muscle strength in the performance of exercise and activities of daily living as well as in preventing disease has become increasingly recognized.13,14 Resistance exercise training increases muscle strength, and it is currently prescribed by the major health organizations for improving health and fitness.15 Cardiovascular disease risk factors have also been associated with aerobic exercise and cardiorespiratory fitness, not only in adults but also in young people.16,17 Whether low-grade inflammation is associated with muscle strength in adolescents is unknown. The aim of our study was to examine the associations between inflammatory proteins and muscle strength in adolescents and to determine whether these associations vary in overweight and nonoverweight adolescents.

PARTICIPANTS

The study participants were Spanish adolescents aged 13 to 18½ years from the Alimentación y Valoración del Estado Nutricional de los Adolescentes Españoles (Food and Assessment of the Nutritional Status of Spanish Adolescents) (AVENA) Study. The AVENA Study was designed to assess the health and nutritional status of Spanish adolescents. Study design and sampling procedure have been reported in detail elsewhere.1820 After exclusion of 9 adolescents with concentrations of C-reactive protein greater than 10 mg/L (to convert to nanomoles per liter, multiply by 9.524), the study sample comprised 416 adolescents (230 boys and 186 girls) who had a complete set of inflammatory protein, muscle strength, and cardiorespiratory fitness measurements. A comprehensive verbal description of the nature and purpose of the study was given to both the adolescents and their teachers. Written consent was requested from parents and adolescents, and all adolescents gave verbal assent. Adolescents who had a history of cardiovascular disease, were taking medication at the time of the study, or were pregnant were excluded after completion of the field work. The study protocol was performed in accordance with the ethical standards established in the 1961 Declaration of Helsinki (as revised in Hong Kong in 1989 and in Edinburgh in 2000) and was approved by the Review Committee for Research Involving Human Subjects of the Hospital Universitario Marqués de Valdecilla, Santander, Spain.

The parents completed a questionnaire that addressed the adolescents' previous and current health status. Socioeconomic status was also assessed in the questionnaire and was defined by the educational achievement and occupation of the father. According to this information, and following the recommendation of the Spanish Society for Epidemiology, the adolescents were classified into 5 categories: low, medium-low, medium, medium-high, and high socioeconomic status.

PHYSICAL EXAMINATION

Anthropometric measurements were obtained as described elsewhere.21,22 Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. The BMI categories (nonoverweight and overweight [including obesity]) were computed according to the proposed sex- and age-adjusted BMI cutoff points derived from adult values associated with health risk.23 Skinfold thickness was measured at the biceps, triceps, subscapular, suprailiac, thigh, and calf on the left side of the body to the nearest 0.2 mm using a Holtain skinfold caliper. The sum of 6 skinfolds was used as an indicator of total body fat.22 Body fat percentage was calculated from skinfold thicknesses (triceps and subscapular) using equations from Slaughter et al.24 Fat-free mass (in kilograms) was derived by subtracting fat mass from total body weight.

Identification of pubertal status (stages I-V) was assessed according to Tanner and Whitehouse.25 The standard staging of pubertal maturity describes breast and pubic hair development in girls and genital and pubic hair development in boys.

BLOOD SAMPLING

After overnight fasting, blood samples were collected between 8 and 9:30 AM by venipuncture. High sensitive C-reactive protein, complement factors C3 and C4, and ceruloplasmin were measured by immunoturbidimetry (AU2700 Biochemistry Analyzer; Olympus, Rungis, France). Prealbumin was measured by immunoturbidimetry (Roche/Hitachi 912; Roche Diagnostics, Indianapolis, Indiana). Quality control of the assays was assured by the regional health authority. A detailed description of the blood analysis has been reported already.20,26

MUSCLE STRENGTH

Upper body strength was assessed by handgrip strength test, and lower body strength was assessed by the standing broad jump test. The handgrip strength test was performed on both hands with a hand dynamometer (Takei TKK 5101 Grip-D; Takey, Tokyo, Japan), standing and with the arm completely extended. The standing broad jump test was performed in an indoor rubber-floored gymnasium. The participants were instructed to push off vigorously and jump as far forward as possible, trying to land on both feet. The distance from the take-off line to the point where the back of the heel closest to the take-off line landed on the floor was scored.

A muscle strength score was computed by combining the standardized values of handgrip strength and standing broad jump. Each of these variables was standardized as follows: standardized value = (value − mean)/SD. The standardized values of the handgrip strength obtained with the right and left hands were averaged. The muscle strength score was calculated as the mean of the 2 standardized scores (handgrip strength and standing broad jump). The score was calculated separately for boys and girls and for each age group (13, 14, 15, 16, and 17-18½ years).

CARDIORESPIRATORY FITNESS

Cardiorespiratory fitness was assessed by the 20-m shuttle run test as previously described.27 In brief, participants were required to run between 2 lines 20 m apart in time with an audio signal. The initial speed of the signal was 8.5 km/h and was increased by 0.5 km/h/min (1 minute equal to 1 step). The test was finished when the participant failed to reach the end lines concurrent with the audio signals on 2 consecutive occasions. Otherwise, the test ended when the participant stopped because of fatigue. Cardiorespiratory fitness was considered to be the number of steps completed. Detailed methodology of these fitness tests have been reported elsewhere.28

STATISTICAL ANALYSES

All the residuals showed a satisfactory pattern after skinfold thickness and C-reactive protein, C3, C4, ceruloplasmin, and prealbumin values were normalized by natural logarithm transformation. Sex differences were analyzed by 1-way analysis of variance and adjusted for mass significance as described by Holm.29 Nominal data were analyzed using χ2 tests. Partial correlations were used to examine bivariate correlations between cardiorespiratory fitness and muscle strength after controlling for sex. Mean values of inflammatory proteins, skinfold thickness, body fat percentage, and fat-free mass in overweight and nonoverweight adolescents were compared by 1-way analysis of variance.

Multiple regression was used to study the association between inflammatory proteins and muscle strength after controlling for sex, age, pubertal status, weight, height, socioeconomic status, and cardiorespiratory fitness. A separate regression model was performed for every outcome variable (ie, C-reactive protein, C3, C4, ceruloplasmin, and prealbumin levels). Because no significant interaction was found with sex, all the analyses were performed with the male and female adolescents together to have a stronger statistical power.

The associations between inflammatory proteins and muscle strength were also examined separately for overweight and nonoverweight adolescents owing to the strong differences observed in inflammatory proteins and body composition–related variables. Moreover, a significant interaction was observed between BMI categories and muscle strength. The regression analyses were controlled for sex, age, pubertal status, socioeconomic status, and cardiorespiratory fitness. Further analyses were performed additionally controlling for skinfold thickness (or body fat percentage) and fat-free mass. The SPSS, version 15.0 (SPSS Inc, Chicago, Illinois), was used to perform all the analyses. P ≤ .05 was considered significant.

All adolescents (N = 416) had a complete set of data, with the exception of pubertal status and socioeconomic status data, which were not available in 37 (9%) and 83 (20%) adolescents, respectively. The descriptive characteristics of the study sample are presented in Table 1. The analysis of variance showed that adolescent boys had significantly higher levels of ceruloplasmin than adolescent girls as well as higher fat-free mass, cardiorespiratory fitness, handgrip strength, and standing broad jump. The results of the partial correlation showed that cardiorespiratory fitness was significantly associated with both handgrip strength (r = 0.148, P < .01) and standing broad jump (r = 0.746, P < .001) as well as with muscle strength score (r = 0.339, P < .001) after controlling for sex.

Table Graphic Jump LocationTable 1. Physical Characteristics of Study Sample

The statistics of the regression analysis showing the association between inflammatory proteins and muscle strength after controlling for sex, age, pubertal status, weight, height, socioeconomic status, and cardiorespiratory fitness are presented in Table 2. C-reactive protein, C3, and ceruloplasmin levels were negatively associated with muscle strength, whereas C4 and prealbumin were not significantly associated with muscle strength. Inflammatory proteins were not significantly associated with cardiorespiratory fitness. The results did not change when the analyses were controlled for BMI or body fat (expressed as either skinfold thickness or body fat percentage) instead of weight and height.

Table Graphic Jump LocationTable 2. Regression Coefficients, SEM, and Standardized Coefficient of Determination Showing the Association Between Inflammatory Proteins and Muscle Strengtha

Mean values of inflammatory proteins and body composition variables by BMI categories are presented in Table 3. The results of the analysis of variance showed that overweight adolescents had significantly higher levels of C-reactive protein, C3, C4, and ceruloplasmin than nonoverweight adolescents. Moreover, overweight adolescents had significantly higher skinfold thickness, body fat percentage, and fat-free mass than their nonoverweight counterparts.

Table Graphic Jump LocationTable 3. Inflammatory Proteins and Body Composition Variables by Body Mass Index Categories

The results of the regression analysis showing the association between inflammatory proteins and muscle strength in overweight and nonoverweight adolescents after controlling for sex, age, pubertal status, socioeconomic status, and cardiorespiratory fitness are presented in Table 4. C-reactive protein and prealbumin were associated with muscle strength in overweight adolescents, whereas no association was found in the nonoverweight group. Ceruloplasmin, C3, and C4 levels were not significantly associated with muscle strength in either overweight or nonoverweight adolescents. The results did not change when the analyses were additionally controlled for skinfold thickness or body fat percentage. Likewise, the inclusion of fat-free mass in the regression model did not alter the results. No significant effect of pubertal status on the outcome was observed in any of the analyses performed (data not shown).

Table Graphic Jump LocationTable 4. Regression Coefficients, SEM, and Standardized Coefficient of Determination Showing the Association Between Inflammatory Proteins and Muscle Strength in Overweight and Nonoverweight Adolescentsa

Both overweight and nonoverweight adolescents were divided into 3 groups (tertiles) of muscle strength (low, middle, and high). The analysis of covariance with Bonferroni adjustment for sex, age, pubertal status, socioeconomic status, and cardiorespiratory fitness showed that overweight adolescents with high muscle strength (third tertile) had significantly lower values of C-reactive protein than overweight adolescents with low muscle strength (first tertile) (Figure 1). Moreover, overweight adolescents with middle or high muscle strength (second and third tertile, respectively) had significantly higher levels of prealbumin than overweight adolescents with low muscle strength (Figure 2). Overweight adolescents with high muscle strength had significantly lower skinfold thickness and body fat percentage than overweight adolescents with low muscle strength (skinfold thickness, 49.3 vs 53.4 mm, respectively, P = .03; body fat percentage, 30.1% vs 33.8%, respectively, P = .001). Furthermore, overweight adolescents with high muscle strength also had significantly higher fat-free mass levels than overweight adolescents with low muscle strength (52.6 vs 51.4 kg, respectively, P = .001).

Place holder to copy figure label and caption
Figure 1.

Mean values of C-reactive protein (log transformed) stratified in tertiles by muscle strength (low, middle, and high) in overweight (including obese) and nonoverweight adolescents. Error bars represent standard errors of the mean. *Indicates a significant difference (P = .04) was observed between overweight adolescents with high muscle strength (third tertile) and overweight adolescents with low muscle strength (first tertile). To convert C-reactive protein to nanomoles per liter, multiply by 9.524.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Mean values of prealbumin (log transformed) stratified in tertiles by muscle strength (low, middle, and high) in overweight (including obese) and nonoverweight adolescents. Error bars represent standard errors of the mean. *Indicates a significant difference (P = .048) was observed between overweight adolescents with middle muscle strength (second tertile) and overweight adolescents with low muscle strength (first tertile); †, a significant difference (P = .004) was observed between overweight adolescents with high muscle strength (third tertile) and overweight adolescents with low muscle strength (first tertile). To convert prealbumin to milligrams per liter, multiply by 10.

Graphic Jump Location

The primary findings of this study show that (1) C-reactive protein, C3, and ceruloplasmin are negatively associated with muscle strength in adolescence and (2) C-reactive protein and prealbumin are associated with muscle strength in overweight adolescents after controlling for different confounders including cardiorespiratory fitness. Moreover, we observed an increased low-grade inflammation in overweight adolescents compared with their nonoverweight counterparts, which confirms previous findings.3,4,26 Taken together, these findings suggest that interventions designed to prevent low-grade inflammation and related metabolic disorders should focus not only on reducing fatness but also on improving muscle fitness. To the best of our knowledge, this is the first population-based study showing the association between low-grade inflammation and muscle strength in adolescents.

The association between inflammatory proteins and muscle strength has only been examined in a few studies in adults. Two cross-sectional studies have shown a negative association of C-reactive protein, IL-6 (interleukin-6), and tumor necrosis factor-α with muscle strength.9,11 Additionally, 1 prospective study found that higher levels of IL-6 and C-reactive protein were associated with loss of muscle strength in older persons.10

Features of metabolic syndrome have also been negatively associated with muscle strength in men.30 Likewise, findings from a prospective study in men suggested that muscle strength may additively protect against the incidence of metabolic syndrome beyond that attributed to cardiorespiratory fitness and that overweight men may benefit more than their nonoverweight counterparts.31 These results concur with those obtained in the present study. That low-grade inflammation was negatively associated with muscle strength after controlling for cardiorespiratory fitness may indicate that muscle strength in young people confer additional benefits beyond those attributed to cardiorespiratory fitness.46,8,16,17,32 We did not find a significant association between inflammatory markers and cardiorespiratory fitness. Findings from the European Youth Heart Study showed that C-reactive protein and C3 were negatively associated with cardiorespiratory fitness and positively associated with body fat (expressed as the sum of 5 skinfolds) in Swedish children aged 9 to 10 years.33 Further analyses revealed that, for most of the variables, body fat was slightly more predictive than cardiorespiratory fitness. In our study, the associations between inflammatory proteins and muscle strength persisted after (separately) controlling for weight and height, BMI, and body fat (expressed as either the sum of 6 skinfolds or as body fat percentage). These findings add supportive evidence to the body of knowledge that suggests that muscle strength is important for health in young people, as it has been shown in adults.911,30,31

It is also noteworthy that the observed associations between C-reactive protein, prealbumin, and muscle strength in overweight adolescents remained significant after controlling for body fat and fat-free mass. This suggests that other mechanisms are involved in these associations. The key role of muscle mass in a number of metabolic processes as well as in the prevention of many pathologic conditions and chronic diseases has recently been highlighted.13,14 The group of overweight adolescents in the present study have higher values of body fat and fat-free mass than the nonoverweight group, which is in agreement with another study in obese children.34 In addition, the group of overweight adolescents with high muscle strength have lower body fat and higher fat-free mass than the overweight group with low muscle strength. Taken together, these results may partially explain why the group of overweight adolescents with high muscle strength are also those with the lowest levels of C-reactive protein and the highest levels of prealbumin. The findings suggest that the deleterious consequences ascribed to high fatness could be counteracted by having high levels of fitness. The role of both body fat and fat-free mass in the association between low-grade inflammation and muscle strength warrants further investigation. The use of more advanced approaches to better estimate both body fat and fat-free mass35 may help to elucidate the role of these 2 tissues in the association between low-grade inflammation and muscle strength.

A high concentration of C-reactive protein is considered a major cardiovascular risk factor,13 and evidence also links C3 and C4 with vascular disease.37 Body fat is known to promote a state of low-grade inflammation,38 which lends credibility to the results obtained in our study. Furthermore, high concentrations of inflammatory proteins have been hypothesized to play a role in the functional decline of older persons through its catabolic effects on skeletal muscle.12,39,40 Collectively, these mechanisms may explain the observed association between C-reactive protein and muscle strength in overweight adolescents. Prealbumin, also known as transthyretin, is a negative acute-phase protein that declines in response to inflammation.41 Other factors, such as starvation and decreased skeletal muscle function, are also known to affect prealbumin concentrations.42 Therefore, the association between prealbumin levels and muscle strength observed in our study in overweight adolescents could be explained by prealbumin's putative association to muscular weakness and the state of increased low-grade inflammation seen in the overweight adolescents.

In light of these results, special efforts should focus on subgroups of adolescents at increased risk of early cardiovascular disease, such as overweight or obese adolescents. As a first step, promotion of regular participation in strength activities may be helpful, since this mode of exercise may be easier and better tolerated than aerobic training for overweight or obese youth.43 Strength training may have a number of beneficial effects for overweight or obese individuals, including increased muscle mass, decreased total and central fat mass, and enhanced insulin sensitivity.15,4447 A recent study in obese men has shown that a 12-week resistance training program (3 d/wk) induces an improvement of whole body insulin sensitivity independent of changes in body composition.44 Moreover, plasma levels of C-reactive protein, adiponectin, IL-1β, IL-6, and tumor necrosis factor-α as well as gene expression of adipokines in abdominal adipose tissue were not changed after the training period. Interventional studies have failed to show significant changes on low-grade inflammation (fibrinogen, plasminogen activator inhibitor 1, and C-reactive protein) in overweight or obese children after completion of an aerobic physical training program.48,49 Nevertheless, further studies are required to show whether resistance exercise can effectively attenuate the moderately increased resting levels of inflammatory proteins as well as reduce the fat mass in overweight adolescents. Increases in muscle strength may also positively influence the levels of cardiorespiratory fitness, since both variables are closely related.

The observations of our study are limited by its cross-sectional design. Prospective and intervention studies are required to draw more robust conclusions on the determining effect of inflammatory proteins on muscle strength. We used a single blood measurement of inflammation that may not accurately reflect long-term inflammatory status. Although we did not include any adolescent with a known underlying cause of infection, we cannot be sure that elevated concentrations were not due to the onset of an infection. However, to minimize the confounding effect of an ongoing infection, adolescents with high concentrations of C-reactive protein (> 10 mg/L) were not included in this study. We should therefore consider the whole sample as healthy, and the modest but significant associations presented here may imply a chronic state of inflammation clinically relevant in the long-term rather than as a short-term diagnostic risk marker.

Rapid and dynamic changes in various metabolic systems, including hormonal regulation, changes in body composition, as well as transient changes in insulin resistance are known to occur during puberty.50 However, we did not measure either sex hormones or insulin, which hamper further study of hormone- and insulin-inflammatory protein relationships in our population. All the analyses were controlled for pubertal status as a measure of biological age. We have shown that pubertal status influences serum lipid and lipoprotein levels in the AVENA Study population,51 whereas, we observed neither an influence on low-grade inflammation nor an interaction with muscle strength.

In conclusion, the results presented in this study indicate that low-grade inflammation is negatively associated with muscle strength in adolescents. The patterns of these associations seem more relevant in overweight adolescents, suggesting that having high levels of muscle strength may counteract the negative consequences ascribed to body fat. More studies are needed to elucidate the role of body fat, fat-free mass, and muscle strength on low-grade inflammation. Intervention studies examining the effect of strength training on muscle mass and inflammatory markers in adolescents are warranted.

Correspondence: Jonatan R. Ruiz, PhD, Department of Physiology, School of Medicine, University of Granada, Avenida de Madrid nº 12, 18071 Granada, Spain (ruizj@ugr.es).

Accepted for Publication: June 13, 2007.

Author Contributions: Dr Ruiz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Ruiz, Moreno, Gonzalez-Gross, Carrero, and Marcos. Acquisition of data: Ruiz, Ortega, Wärnberg, Moreno, Gonzalez-Gross, Marcos, and Gutierrez. Analysis and interpretation of data: Ruiz, Ortega, Wärnberg, Moreno, Carrero, Marcos, Gutierrez, and Sjöström. Drafting of the manuscript: Ruiz. Critical revision of the manuscript for important intellectual content: Ruiz, Ortega, Wärnberg, Moreno, Carrero, Gonzalez-Gross, Marcos, Gutierrez, and Sjöström. Statistical analysis: Ruiz. Obtained funding: Moreno, Carrero, Gonzalez-Gross, Marcos, Gutierrez, Ruiz, and Wärnberg. Administrative, technical, or material support: Ruiz, Moreno, Gonzalez-Gross, Marcos, and Gutierrez. Study supervision: Ruiz, Moreno, Gonzalez-Gross, Marcos, Gutierrez, and Sjöström.

Financial Disclosure: None reported.

Funding/Support: This study was funded by the Spanish Ministry of Health; Fondo Europeo de Desarrollo Regional–Fondo Social Europeo, Fondo de Investigacions Sanitarias (00/0015); grants 05/UPB32/0, 109/UPB31/03 and 13/UPB20/04 from the Consejo Superior de Deportes; grants AP2003-2128, AP-2004-2745, and EX-2006-1670 from the Spanish Ministry of Education; the Margit and Folke Pehrzon Foundation; and scholarships from Panrico, Madaus, and Procter & Gamble.

Additional Contributions: Manuel J. Castillo, MD, PhD, (head of the Evaluación Funcional y Fisología del Ejercicio-Ciencia y Tecnología de la Salud [EFFECTS] 262 Research Group, Department of Physiology, School of Medicine, University of Granada) provided highly valuable comments on the manuscript and played a key role in the study concept, design, and supervision as well as in data collection and funding. Olle Carlsson, PhD, from the Unit for Preventive Nutrition, Department of Biosciences and Nutrition at Novum, Karolinska Institutet, provided statistical expertise.

Järvisalo  MJHarmoinen  AHakanen  M  et al.  Elevated serum C-reactive protein levels and early arterial changes in healthy children. Arterioscler Thromb Vasc Biol 2002;22 (8) 1323- 1328
PubMed
Hansson  GK Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med 2005;352 (16) 1685- 1695
PubMed
Cook  DGMendall  MAWhincup  PH  et al.  C-reactive protein concentration in children: relationship to adiposity and other cardiovascular risk factors. Atherosclerosis 2000;149 (1) 139- 150
PubMed
Nemet  DWang  PFunahashi  T  et al.  Adipocytokines, body composition, and fitness in children. Pediatr Res 2003;53 (1) 148- 152
PubMed
Isasi  CRDeckelbaum  RJTracy  RPStarc  TJBerglund  LShea  S Physical fitness and C-reactive protein level in children and young adults: the Columbia University BioMarkers Study. Pediatrics 2003;111 (2) 332- 338
PubMed
Williams  MJMilne  BJHancox  RJPoulton  R C-reactive protein and cardiorespiratory fitness in young adults. Eur J Cardiovasc Prev Rehabil 2005;12 (3) 216- 220
PubMed
LaMonte  MJDurstine  JLYanowitz  FG  et al.  Cardiorespiratory fitness and C-reactive protein among a tri-ethnic sample of women. Circulation 2002;106 (4) 403- 406
PubMed
Wärnberg  JRuiz  JRSjöström  M  et al.  Association of fitness and fatness to low-grade systemic inflammation in adolescents: The AVENA study [abstract]. Med Sci Sports Exerc 2006;38S8
Visser  MPahor  MTaaffe  DR  et al.  Relationship of interleukin-6 and tumor necrosis factor-alpha with muscle mass and muscle strength in elderly men and women: the Health ABC Study. J Gerontol A Biol Sci Med Sci 2002;57 (5) M326- M332
PubMed
Schaap  LAPluijm  SMDeeg  DJVisser  M Inflammatory markers and loss of muscle mass (sarcopenia) and strength. Am J Med 2006 Jun;119 (6) (526) e9- e17
PubMed
Taaffe  DRHarris  TBFerrucci  LRowe  JSeeman  TE Cross-sectional and prospective relationships of interleukin-6 and C-reactive protein with physical performance in elderly persons: MacArthur studies of successful aging. J Gerontol A Biol Sci Med Sci 2000;55 (12) M709- M715
PubMed
Ferrucci  LPenninx  BWVolpato  S  et al.  Change in muscle strength explains accelerated decline of physical function in older women with high interleukin-6 serum levels. J Am Geriatr Soc 2002;50 (12) 1947- 1954
PubMed
Stump  CSHenriksen  EJWei  YSowers  JR The metabolic syndrome: role of skeletal muscle metabolism. Ann Med 2006;38 (6) 389- 402
PubMed
Wolfe  RR The underappreciated role of muscle in health and disease. Am J Clin Nutr 2006;84 (3) 475- 482
PubMed
Pollock  MLFranklin  BABalady  GJ  et al. AHA Science Advisory, Resistance exercise in individuals with and without cardiovascular disease: benefits, rationale, safety, and prescription, an advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association, position paper endorsed by the American College of Sports Medicine. Circulation 2000;101 (7) 828- 833
PubMed
Ruiz  JROrtega  FBRizzo  NS  et al.  High cardiovascular fitness is associated with low metabolic risk score in children: The European Youth Heart Study. Pediatr Res 2007;61 (3) 350- 355
PubMed
Ruiz  JRSola  RGonzalez-Gross  M  et al.  Cardiovascular fitness is negatively associated with homocysteine levels in female adolescents. Arch Pediatr Adolesc Med 2007;161 (2) 166- 171
PubMed
González-Gross  MCastillo  MJMoreno  L  et al.  Feeding and assessment of nutritional status of Spanish adolescents (AVENA study): evaluation of risks and interventional proposal, I: methodology [in Spanish]. Nutr Hosp 2003;18 (1) 15- 28
PubMed
Moreno  LAJoyanes  MMesana  MI  et al.  Harmonization of anthropometric measurements for a multicenter nutrition survey in Spanish adolescents. Nutrition 2003;19 (6) 481- 486
PubMed
Ruiz  JROrtega  FBMoreno  LA  et al.  Serum lipid and lipoprotein reference values of Spanish adolescents: The AVENA Study. Soz Praventivmed 2006;51 (2) 99- 109
PubMed
Moreno  LAMesana  MIFleta  J  et al.  Overweight, obesity and body fat composition in Spanish adolescents: The AVENA Study. Ann Nutr Metab 2005;49 (2) 71- 76
PubMed
Moreno  LAMesana  MIGonzalez-Gross  M  et al.  Anthropometric body fat composition reference values in Spanish adolescents: The AVENA Study. Eur J Clin Nutr 2006;60 (2) 191- 196
PubMed
Cole  TJBellizzi  MCFlegal  KMDietz  WH Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320 (7244) 1240- 1243
PubMed
Slaughter  MHLohman  TGBoileau  RA  et al.  Skinfold equations for estimation of body fatness in children and youth. Hum Biol 1988;60 (5) 709- 723
PubMed
Tanner  JMWhitehouse  RH Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty. Arch Dis Child 1976;51 (3) 170- 179
PubMed
Wärnberg  JNova  EMoreno  LA  et al.  Inflammatory proteins are related to total and abdominal adiposity in a healthy adolescent population: the AVENA Study. Am J Clin Nutr 2006;84 (3) 505- 512
PubMed
Léger  LAMercier  DGadoury  CLambert  J The multistage 20 metre shuttle run test for aerobic fitness. J Sports Sci 1988;6 (2) 93- 101
PubMed
Ortega  FBRuiz  JRCastillo  MJ  et al.  Low level of physical fitness in Spanish adolescents: relevance for future cardiovascular health (AVENA study) [in Spanish]. Rev Esp Cardiol 2005;58 (8) 898- 909
PubMed
Holm  S A simple sequentially rejective multiple test procedure. Scand J Stat 1979;665- 70
Jurca  RLamonte  MJChurch  TS  et al.  Associations of muscle strength and fitness with metabolic syndrome in men. Med Sci Sports Exerc 2004;36 (8) 1301- 1307
PubMed
Jurca  RLamonte  MJBarlow  CEKampert  JBChurch  TSBlair  SN Association of muscular strength with incidence of metabolic syndrome in men. Med Sci Sports Exerc 2005;37 (11) 1849- 1855
PubMed
Ruiz  JRRizzo  NSOrtega  FBLoit  HMVeidebaum  TSjöström  M Markers of insulin resistance are associated with fatness and fitness in school-aged children: the European Youth Heart Study. Diabetologia 2007;50 (7) 1401- 1408
PubMed
Ruiz  JROrtega  FBWärnberg  JSjöström  M Associations of low-grade inflammation with physical activity, fitness and fatness in prepubertal children: the European Youth Heart Study [published online ahead of print July 24, 2007]. Int J Obes (Lond) 2007;31 (10) 1545- 1551
PubMed10.1038/sj.ijo.0803693
Wells  JCFewtrell  MSWilliams  JEHaroun  DLawson  MSCole  TJ Body composition in normal weight, overweight and obese children: matched case-control analyses of total and regional tissue masses, and body composition trends in relation to relative weight [published online ahead of print June 13, 2006]. Int J Obes (Lond) 2006;30 (10) 1506- 1513
PubMed10.1038/sj.ijo.0803402
Kim  JShen  WGallagher  D  et al.  Total-body skeletal muscle mass: estimation by dual-energy X-ray absorptiometry in children and adolescents. Am J Clin Nutr 2006;84 (5) 1014- 1020
PubMed
Ridker  PMStampfer  MJRifai  N Novel risk factors for systemic atherosclerosis: a comparison of C-reactive protein, fibrinogen, homocysteine, lipoprotein(a), and standard cholesterol screening as predictors of peripheral arterial disease. JAMA 2001;285 (19) 2481- 2485
PubMed
Dernellis  JPanaretou  M Effects of C-reactive protein and the third and fourth components of complement (C3 and C4) on incidence of atrial fibrillation. Am J Cardiol 2006;97 (2) 245- 248
PubMed
Wellen  KEHotamisligil  GS Inflammation, stress, and diabetes. J Clin Invest 2005;115 (5) 1111- 1119
PubMed
Penninx  BWKritchevsky  SBNewman  AB  et al.  Inflammatory markers and incident mobility limitation in the elderly. J Am Geriatr Soc 2004;52 (7) 1105- 1113
PubMed
Cesari  MPenninx  BWPahor  M  et al.  Inflammatory markers and physical performance in older persons: the InCHIANTI study. J Gerontol A Biol Sci Med Sci 2004;59 (3) 242- 248
PubMed
Gabay  CKushner  I Acute-phase proteins and other systemic responses to inflammation. N Engl J Med 1999;340 (6) 448- 454
PubMed
Lennmarken  CSandstedt  SSchenck  HVLarsson  J The effect of starvation on skeletal muscle function in man. Clin Nutr 1986;5 (2) 99- 103
PubMed
Deforche  BLefevre  JDe Bourdeaudhuij  IHills  APDuquet  WBouckaert  J Physical fitness and physical activity in obese and nonobese Flemish youth. Obes Res 2003;11 (3) 434- 441
PubMed
Klimcakova  EPolak  JMoro  C  et al.  Dynamic strength training improves insulin sensitivity without altering plasma levels and gene expression of adipokines in subcutaneous adipose tissue in obese men. J Clin Endocrinol Metab 2006;91 (12) 5107- 5112
PubMed
Shaibi  GQCruz  MLBall  GD  et al.  Effects of resistance training on insulin sensitivity in overweight Latino adolescent males. Med Sci Sports Exerc 2006;38 (7) 1208- 1215
PubMed
Fenicchia  LMKanaley  JAAzevedo  JL  Jr  et al.  Influence of resistance exercise training on glucose control in women with type 2 diabetes. Metabolism 2004;53 (3) 284- 289
PubMed
Ibañez  JIzquierdo  MArguelles  I  et al.  Twice-weekly progressive resistance training decreases abdominal fat and improves insulin sensitivity in older men with type 2 diabetes. Diabetes Care 2005;28 (3) 662- 667
PubMed
Ferguson  MAGutin  BOwens  SBarbeau  PTracy  RPLitaker  M Effects of physical training and its cessation on the hemostatic system of obese children. Am J Clin Nutr 1999;69 (6) 1130- 1134
PubMed
Kelly  ASWetzsteon  RJKaiser  DRSteinberger  JBank  AJDengel  DR Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise. J Pediatr 2004;145 (6) 731- 736
PubMed
Cruz  MLShaibi  GQWeigensberg  MJSpruijt-Metz  DBall  GDGoran  MI Pediatric obesity and insulin resistance: chronic disease risk and implications for treatment and prevention beyond body weight modification. Annu Rev Nutr 2005;25435- 468
PubMed
Ruiz  JROrtega  FBTresaco  B  et al.  Serum lipids, body mass index and waist circumference during pubertal development in Spanish adolescents: the AVENA Study. Horm Metab Res 2006;38 (12) 832- 837
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

Mean values of C-reactive protein (log transformed) stratified in tertiles by muscle strength (low, middle, and high) in overweight (including obese) and nonoverweight adolescents. Error bars represent standard errors of the mean. *Indicates a significant difference (P = .04) was observed between overweight adolescents with high muscle strength (third tertile) and overweight adolescents with low muscle strength (first tertile). To convert C-reactive protein to nanomoles per liter, multiply by 9.524.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Mean values of prealbumin (log transformed) stratified in tertiles by muscle strength (low, middle, and high) in overweight (including obese) and nonoverweight adolescents. Error bars represent standard errors of the mean. *Indicates a significant difference (P = .048) was observed between overweight adolescents with middle muscle strength (second tertile) and overweight adolescents with low muscle strength (first tertile); †, a significant difference (P = .004) was observed between overweight adolescents with high muscle strength (third tertile) and overweight adolescents with low muscle strength (first tertile). To convert prealbumin to milligrams per liter, multiply by 10.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Physical Characteristics of Study Sample
Table Graphic Jump LocationTable 2. Regression Coefficients, SEM, and Standardized Coefficient of Determination Showing the Association Between Inflammatory Proteins and Muscle Strengtha
Table Graphic Jump LocationTable 3. Inflammatory Proteins and Body Composition Variables by Body Mass Index Categories
Table Graphic Jump LocationTable 4. Regression Coefficients, SEM, and Standardized Coefficient of Determination Showing the Association Between Inflammatory Proteins and Muscle Strength in Overweight and Nonoverweight Adolescentsa

References

Järvisalo  MJHarmoinen  AHakanen  M  et al.  Elevated serum C-reactive protein levels and early arterial changes in healthy children. Arterioscler Thromb Vasc Biol 2002;22 (8) 1323- 1328
PubMed
Hansson  GK Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med 2005;352 (16) 1685- 1695
PubMed
Cook  DGMendall  MAWhincup  PH  et al.  C-reactive protein concentration in children: relationship to adiposity and other cardiovascular risk factors. Atherosclerosis 2000;149 (1) 139- 150
PubMed
Nemet  DWang  PFunahashi  T  et al.  Adipocytokines, body composition, and fitness in children. Pediatr Res 2003;53 (1) 148- 152
PubMed
Isasi  CRDeckelbaum  RJTracy  RPStarc  TJBerglund  LShea  S Physical fitness and C-reactive protein level in children and young adults: the Columbia University BioMarkers Study. Pediatrics 2003;111 (2) 332- 338
PubMed
Williams  MJMilne  BJHancox  RJPoulton  R C-reactive protein and cardiorespiratory fitness in young adults. Eur J Cardiovasc Prev Rehabil 2005;12 (3) 216- 220
PubMed
LaMonte  MJDurstine  JLYanowitz  FG  et al.  Cardiorespiratory fitness and C-reactive protein among a tri-ethnic sample of women. Circulation 2002;106 (4) 403- 406
PubMed
Wärnberg  JRuiz  JRSjöström  M  et al.  Association of fitness and fatness to low-grade systemic inflammation in adolescents: The AVENA study [abstract]. Med Sci Sports Exerc 2006;38S8
Visser  MPahor  MTaaffe  DR  et al.  Relationship of interleukin-6 and tumor necrosis factor-alpha with muscle mass and muscle strength in elderly men and women: the Health ABC Study. J Gerontol A Biol Sci Med Sci 2002;57 (5) M326- M332
PubMed
Schaap  LAPluijm  SMDeeg  DJVisser  M Inflammatory markers and loss of muscle mass (sarcopenia) and strength. Am J Med 2006 Jun;119 (6) (526) e9- e17
PubMed
Taaffe  DRHarris  TBFerrucci  LRowe  JSeeman  TE Cross-sectional and prospective relationships of interleukin-6 and C-reactive protein with physical performance in elderly persons: MacArthur studies of successful aging. J Gerontol A Biol Sci Med Sci 2000;55 (12) M709- M715
PubMed
Ferrucci  LPenninx  BWVolpato  S  et al.  Change in muscle strength explains accelerated decline of physical function in older women with high interleukin-6 serum levels. J Am Geriatr Soc 2002;50 (12) 1947- 1954
PubMed
Stump  CSHenriksen  EJWei  YSowers  JR The metabolic syndrome: role of skeletal muscle metabolism. Ann Med 2006;38 (6) 389- 402
PubMed
Wolfe  RR The underappreciated role of muscle in health and disease. Am J Clin Nutr 2006;84 (3) 475- 482
PubMed
Pollock  MLFranklin  BABalady  GJ  et al. AHA Science Advisory, Resistance exercise in individuals with and without cardiovascular disease: benefits, rationale, safety, and prescription, an advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association, position paper endorsed by the American College of Sports Medicine. Circulation 2000;101 (7) 828- 833
PubMed
Ruiz  JROrtega  FBRizzo  NS  et al.  High cardiovascular fitness is associated with low metabolic risk score in children: The European Youth Heart Study. Pediatr Res 2007;61 (3) 350- 355
PubMed
Ruiz  JRSola  RGonzalez-Gross  M  et al.  Cardiovascular fitness is negatively associated with homocysteine levels in female adolescents. Arch Pediatr Adolesc Med 2007;161 (2) 166- 171
PubMed
González-Gross  MCastillo  MJMoreno  L  et al.  Feeding and assessment of nutritional status of Spanish adolescents (AVENA study): evaluation of risks and interventional proposal, I: methodology [in Spanish]. Nutr Hosp 2003;18 (1) 15- 28
PubMed
Moreno  LAJoyanes  MMesana  MI  et al.  Harmonization of anthropometric measurements for a multicenter nutrition survey in Spanish adolescents. Nutrition 2003;19 (6) 481- 486
PubMed
Ruiz  JROrtega  FBMoreno  LA  et al.  Serum lipid and lipoprotein reference values of Spanish adolescents: The AVENA Study. Soz Praventivmed 2006;51 (2) 99- 109
PubMed
Moreno  LAMesana  MIFleta  J  et al.  Overweight, obesity and body fat composition in Spanish adolescents: The AVENA Study. Ann Nutr Metab 2005;49 (2) 71- 76
PubMed
Moreno  LAMesana  MIGonzalez-Gross  M  et al.  Anthropometric body fat composition reference values in Spanish adolescents: The AVENA Study. Eur J Clin Nutr 2006;60 (2) 191- 196
PubMed
Cole  TJBellizzi  MCFlegal  KMDietz  WH Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320 (7244) 1240- 1243
PubMed
Slaughter  MHLohman  TGBoileau  RA  et al.  Skinfold equations for estimation of body fatness in children and youth. Hum Biol 1988;60 (5) 709- 723
PubMed
Tanner  JMWhitehouse  RH Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty. Arch Dis Child 1976;51 (3) 170- 179
PubMed
Wärnberg  JNova  EMoreno  LA  et al.  Inflammatory proteins are related to total and abdominal adiposity in a healthy adolescent population: the AVENA Study. Am J Clin Nutr 2006;84 (3) 505- 512
PubMed
Léger  LAMercier  DGadoury  CLambert  J The multistage 20 metre shuttle run test for aerobic fitness. J Sports Sci 1988;6 (2) 93- 101
PubMed
Ortega  FBRuiz  JRCastillo  MJ  et al.  Low level of physical fitness in Spanish adolescents: relevance for future cardiovascular health (AVENA study) [in Spanish]. Rev Esp Cardiol 2005;58 (8) 898- 909
PubMed
Holm  S A simple sequentially rejective multiple test procedure. Scand J Stat 1979;665- 70
Jurca  RLamonte  MJChurch  TS  et al.  Associations of muscle strength and fitness with metabolic syndrome in men. Med Sci Sports Exerc 2004;36 (8) 1301- 1307
PubMed
Jurca  RLamonte  MJBarlow  CEKampert  JBChurch  TSBlair  SN Association of muscular strength with incidence of metabolic syndrome in men. Med Sci Sports Exerc 2005;37 (11) 1849- 1855
PubMed
Ruiz  JRRizzo  NSOrtega  FBLoit  HMVeidebaum  TSjöström  M Markers of insulin resistance are associated with fatness and fitness in school-aged children: the European Youth Heart Study. Diabetologia 2007;50 (7) 1401- 1408
PubMed
Ruiz  JROrtega  FBWärnberg  JSjöström  M Associations of low-grade inflammation with physical activity, fitness and fatness in prepubertal children: the European Youth Heart Study [published online ahead of print July 24, 2007]. Int J Obes (Lond) 2007;31 (10) 1545- 1551
PubMed10.1038/sj.ijo.0803693
Wells  JCFewtrell  MSWilliams  JEHaroun  DLawson  MSCole  TJ Body composition in normal weight, overweight and obese children: matched case-control analyses of total and regional tissue masses, and body composition trends in relation to relative weight [published online ahead of print June 13, 2006]. Int J Obes (Lond) 2006;30 (10) 1506- 1513
PubMed10.1038/sj.ijo.0803402
Kim  JShen  WGallagher  D  et al.  Total-body skeletal muscle mass: estimation by dual-energy X-ray absorptiometry in children and adolescents. Am J Clin Nutr 2006;84 (5) 1014- 1020
PubMed
Ridker  PMStampfer  MJRifai  N Novel risk factors for systemic atherosclerosis: a comparison of C-reactive protein, fibrinogen, homocysteine, lipoprotein(a), and standard cholesterol screening as predictors of peripheral arterial disease. JAMA 2001;285 (19) 2481- 2485
PubMed
Dernellis  JPanaretou  M Effects of C-reactive protein and the third and fourth components of complement (C3 and C4) on incidence of atrial fibrillation. Am J Cardiol 2006;97 (2) 245- 248
PubMed
Wellen  KEHotamisligil  GS Inflammation, stress, and diabetes. J Clin Invest 2005;115 (5) 1111- 1119
PubMed
Penninx  BWKritchevsky  SBNewman  AB  et al.  Inflammatory markers and incident mobility limitation in the elderly. J Am Geriatr Soc 2004;52 (7) 1105- 1113
PubMed
Cesari  MPenninx  BWPahor  M  et al.  Inflammatory markers and physical performance in older persons: the InCHIANTI study. J Gerontol A Biol Sci Med Sci 2004;59 (3) 242- 248
PubMed
Gabay  CKushner  I Acute-phase proteins and other systemic responses to inflammation. N Engl J Med 1999;340 (6) 448- 454
PubMed
Lennmarken  CSandstedt  SSchenck  HVLarsson  J The effect of starvation on skeletal muscle function in man. Clin Nutr 1986;5 (2) 99- 103
PubMed
Deforche  BLefevre  JDe Bourdeaudhuij  IHills  APDuquet  WBouckaert  J Physical fitness and physical activity in obese and nonobese Flemish youth. Obes Res 2003;11 (3) 434- 441
PubMed
Klimcakova  EPolak  JMoro  C  et al.  Dynamic strength training improves insulin sensitivity without altering plasma levels and gene expression of adipokines in subcutaneous adipose tissue in obese men. J Clin Endocrinol Metab 2006;91 (12) 5107- 5112
PubMed
Shaibi  GQCruz  MLBall  GD  et al.  Effects of resistance training on insulin sensitivity in overweight Latino adolescent males. Med Sci Sports Exerc 2006;38 (7) 1208- 1215
PubMed
Fenicchia  LMKanaley  JAAzevedo  JL  Jr  et al.  Influence of resistance exercise training on glucose control in women with type 2 diabetes. Metabolism 2004;53 (3) 284- 289
PubMed
Ibañez  JIzquierdo  MArguelles  I  et al.  Twice-weekly progressive resistance training decreases abdominal fat and improves insulin sensitivity in older men with type 2 diabetes. Diabetes Care 2005;28 (3) 662- 667
PubMed
Ferguson  MAGutin  BOwens  SBarbeau  PTracy  RPLitaker  M Effects of physical training and its cessation on the hemostatic system of obese children. Am J Clin Nutr 1999;69 (6) 1130- 1134
PubMed
Kelly  ASWetzsteon  RJKaiser  DRSteinberger  JBank  AJDengel  DR Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise. J Pediatr 2004;145 (6) 731- 736
PubMed
Cruz  MLShaibi  GQWeigensberg  MJSpruijt-Metz  DBall  GDGoran  MI Pediatric obesity and insulin resistance: chronic disease risk and implications for treatment and prevention beyond body weight modification. Annu Rev Nutr 2005;25435- 468
PubMed
Ruiz  JROrtega  FBTresaco  B  et al.  Serum lipids, body mass index and waist circumference during pubertal development in Spanish adolescents: the AVENA Study. Horm Metab Res 2006;38 (12) 832- 837
PubMed

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