Cardiac autonomic modulation in obese and eutrophic children: systematic review and metaanalysis

Santos, Pábula Oliveira dos; Borges, Grasiely Faccin

doi:10.5007/1980-0037.2018v20n3p352

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Revista Brasileira de Cineantropometria & Desempenho Humano

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Review Article • Rev. bras. cineantropom. desempenho hum 20 (3) • May-Jun 2018 • https://doi.org/10.5007/1980-0037.2018v20n3p352 copy

Cardiac autonomic modulation in obese and eutrophic children: systematic review and metaanalysis

Modulação autonômica cardíaca em crianças obesas e eutróficas: revisão sistemática e metanálise

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study aimed to verify the influence of childhood obesity on the regulation of cardiac autonomic modulation through the heart rate variability of obese and eutrophic children. The study consisted of a systematic review and meta-analysis in five PubMed, Scielo, Cochrane Library, BVS/Lilacs and Medline databases. Of the 60 articles found, 15 met the pre-established criteria. These studies were submitted to evaluation of methodological quality and risk of bias, and the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies ( JBI) was applied. Meta-analysis was performed with the Review Manager 5.3 software for variables related to the alteration of cardiac autonomic modulation. Fifteen studies were used for meta-analysis, all were classified with high methodological quality (7 to 9 points), 13 presented results showing alteration of autonomic cardiac modulation in obese children in comparison with eutrophic children, and only two presented indicatives that refute this hypothesis. The present study identified reduction in the parasympathetic activity of the obese group in relation to the eutrophic group through the variables studied. The use of RMSSD, pNN50 and SDNN variables is recommended in future studies, as their results were significant for this meta-analysis.

Key words
Autonomic nervous system; Heart rate; Pediatric obesity

Author	Title	Sample	Assessed Indexes	Conclusion
Ancona et al.⁶6 Ancona MC, Scodeler NF, Guidi RB, Paschoal MA. Variabilidade de frequência cardíaca em crianças eutróficas e obesas nas posições supina e bípede. Rev Ciênc Méd 2009; 18(2): 69-79.	Heart rate variability in eutrophic and obese children in the supine and bipedal positions	15 obese 15 eutrophic	Anthropometric charac-teristics, mean iRR (ms), RMSSD (ms), pNN50, BF, AF, mean HR	The cardiac autonomic modulation in situations of controlled rest and in biped position is not influenced by this degree of childhood obesity.
Cozzolino et al. ²²22 Cozzolino D, Esposito K, Palmiero G, De Bellis A, Furlan R, Perrotta S et al. Cardiac autonomic regulation in response to a mixed meal is impaired in obese children and adolescents: The role played by insulin resistance. J Clin Endocrinol Metab 2014; 99(9):3199–207.	Cardiac Autonomic Regulation in Response to a Mixed Meal Is Im-paired in Obese Children and Adolescents: The Role Played by Insulin Resistance.	33 obese 30 eutrophic (35 obese insulin-resistant patients excluded from the study)^* * Studies that contained in addition to the obese and eutrophic groups, the sample relative to another previous group was discarded.	Anthropometric measure-ments, BF, AF, mean iRR (ms), RMSSD (ms), pNN50, BF, Af, mean HR	The findings of the present study demonstrate that cardiac autonomic regulation both at rest and in response to mixed meal intake is abnormal in obese children and adolescents, despite the normality of conventional cardiac reflex tests.
Freitas et al. ²⁰20 Freitas IMG, Miranda JA, Mira PAC, Lanna CMM, Lima JRP, Laterza MC. Cardiac autonomic dysfunction in obese normotensive children and adolescents. Rev Paul Pediatr 2014; 32(2):244-9.	Cardiac autonomic dysfunction in obese normotensive children and adolescents.	31 obese 35 eutrophic	Anthropometric measures, BF, AF, mean iRR (ms), RMSSD (ms), pNN50, mean HR, SDNN	Obese normotensive children and adolescents present compromised cardiac autonomic control
Kaufmanet al. ²¹21 Kaufman CL, Kaiser DR, Steinberger J, Kelly AS, Dengel DR. Relationships of cardiac autonomic function with metabolic abnormalities in childhood obesity. Obesity 2007;15(5):1164 –71.	Relationships of Cardiac Autonomic Function With Metabolic Abnor-malities in Childhood Obesity.	16 obese 10 eutrophic (10 overweight excluded from the study)^* * Studies that contained in addition to the obese and eutrophic groups, the sample relative to another previous group was discarded.	Anthropometric measures, BF, AF, mean HR	The present study presents new data indicating that obese children, but not overweight children, are characterized by dysfunction of the cardiac autonomic system compared to normal weight children and that the relationship between the cardiac autonomic system function and leptin, insulin resistance, oxidative stress and inflammation, are mainly mediated by fat mass.
Lira et al. ¹⁷17 Lira FAS, Brasileiro-Santos MS, Borba VVL, Costa MJC, Dantas PROF, Santos AC. Influência da vitamina C na modulação autonômica cardíaca no repouso e durante o exercício isométrico em crianças obesas. Rev Bras Saúde Matern Infant 2012;12(3):259-67.	Influence of vitamin C on cardiac modulation autonomy at rest and during isometric exercise in obese children	21 obese 8 eutrophic	Anthropometric measures, BF, AF, mean HR	Obese children have greater sympathetic activity and lower vagal activity at rest and during isometric exercise when compared to eutrophic children.
Latchman et al. ¹⁹19 Latchman PL, Mathur M, Bartels MN, Axtell RS, Meersman RE. Impaired autonomic function in normotensive obese children. Clin Auton Res 2011; 21(5):319–23.	Impaired autonomic function in normotensive obese children.	18 obese19 eutrophic	Anthropometric measures, BF, AF, mean HR	It presents direct clinical implications of the apparent baroreflex sensitivity reg-ulated in obese children, independently of the fact that they are normotensive, in addition to an unfavorable change in the autonomic modulation.
Lazarova et al. ²³23 Lazarova Z, Tonhajzerova I, Trunkvalterova Z, Brozmanova A, Honzíková N, Javorka K, et al. Baroreflex sensitivity is reduced in obese normotensive children and adolescents. Can J Physiol Pharmacol 2009; 87(7):565–71.	Baroreflex sensitivity is reduced in obese normotensive children and adolescents.	20 obese 20 eutrophic	Anthropometric measure-ments, mean iRR (ms)	Baroreflex sensitivity is significantly reduced in obese children and adolescents compared to non-obese controls.
Martini etal. ¹⁶16 Martini G, Riva P, Rabbia F, Molini V, Ferrero GB, Cerutti F. Heart rate variability in childhood obesity. Clin Auton Res 2001;11(2):87-91.	Heart rate variability in childhood obesity.	32 obese 13 eutrophic	Anthropometric measures, mean iRR (ms), RMSSD (ms), pNN50, mean HR	They suggest that a sympathetic-vagal imbalance, characterized by a primary decrease in parasympathetic activity with relative prevalence of sympathetic activity, is present in pediatric obesity.
Nagai etal. ¹⁵15 Nagai N, Matsumoto T, Kita H, Moritani T. Autonomic nervous system activity and the state and development of obesity in japanese school children. Obes Res 2003; 11(1): 25-32.	Autonomic Nervous System Activity and the State and Development of Obesity in Japanese School Children.	42 obese 42 eutrophic	Anthropometric measure-ments, mean HR	They indicate that childhood obesity is closely related to the reduction of activi-ties of the Sympathetic Nervous System and Parasympathetic Nervous System.
Paschoal et al. ¹⁸18 Paschoal MA, Trevizan PF, Scodeler NF. Variabilidade da frequência cardíaca, lípides e capacidade física de crianças obesas e não-obesas. Arq Bras Cardiol 2009; 93(3):239-46.	Variability of Heart Rate, Lipids and Physical Ability of Obese and Non-Obese Children	15 obese 15 eutrophic	Anthropometric measures, mean iRR (ms), RMSSD (ms), pNN50, BF, AF, mean FC, SDNN.	Presence of greater cardiac sympathetic activity when in biped position and great reduction of physical capacity docu-mented in incremental effort protocol.
PaschoalandPereira ¹¹11 Paschoal MA, Pereira MC. Modulação autonômica cardíaca nas posições supina e bípede em crianças não obesas, obesas e obesas mórbidas. Rev Ciênc Méd 2010; 19(1-6):33-41.	Cardiac autonomic modulation in the supine and biped positions in non-obese, obese and morbidly obese children	10 obese 10 eutrophic (10 morbidly obese excluded from the study) ^* * Studies that contained in addition to the obese and eutrophic groups, the sample relative to another previous group was discarded.	Anthropometric measures, mean iRR (ms), RMSSD (ms), pNN50, BF, AF, mean HR	There was no significant result that could confirm the interference of childhood obesity on HRV during MPA or during the permanence in the bipedal position.
Rodri-guez-Colon et al. ⁷7 Rodríguez-Colón SM, Bixler EO, Li X, Vgontzas AN, Liao D. Obesity is associated with impaired cardiac autonomic modulation in children. Int J Pediatr Obes 2011;6(2):128–34.	Obesity is associated with impaired cardiac autonomic modulation in children.	91 obese 420 eutrophic	Anthropometric measures, mean HR, RMSSD, SDNN.	Childhood obesity is significantly associated with lower HRV, indicative of sympathetic overflow without opposition to parasympathetic modulation.
Tasçilar et al. ⁸8 Tasçilar ME, Yokusoglu M, Boyraz M, Baysan O, Köz C, Dündaröz R. Cardiac autonomic functions in obese children. J Clin Res Ped Endo 2011;3(2):60-4.	Cardiac Autonomic Func-tions in Obese Children.	32 obese 30 eutrophic	RMSSD (ms), pNN50, BF, AF, SDNN.	Sympathetic dominance in obese children, which was more significant in the insulin resistant subgroup.
Vanderleiet al. ¹⁴14 Vanderlei LCM, Pastre CM, Júnior IFF, Godoy M. F. Índices Geométricos de Variabilidad de la Frecuencia Cardíaca em Niños Obesos y Eutróficos. Arq Bras Cardiol 2010; 95(1): 35-40.	Geometric Indexes of Heart Rate Variability in Obese and Eutrophic Children	61 obese 72 eutrophic	Anthropometric measure-ments	They suggest that obese children have autonomic nervous system modifica-tions, characterized by reduction in parasympathetic activity and general variability.
Vanderlei et al.¹³13 Vanderlei LCM, Pastre CM, Júnior IFF, Godoy MF. Analysis of cardiac autonomicmodulation in obese and eutrophic children. Clinics 2010; 65(8):789-92.	Analysis of cardiac autonomic modulation in obese and eutrophic children.	56 obese 65 eutrophic	Anthropometric measures, mean iRR (ms), RMSSD (ms), pNN50, BF, AF, SDNN	Obese children presented changes in heart rate variability, characterized by a reduction in sympathetic and parasympathetic activity.

(JBI Critical Appraisal Checklist for Prevalence Studies)
Study	1	2	3	4	5	6	7	8	9	Total (No. S)
Ancona et al. ⁶6 Ancona MC, Scodeler NF, Guidi RB, Paschoal MA. Variabilidade de frequência cardíaca em crianças eutróficas e obesas nas posições supina e bípede. Rev Ciênc Méd 2009; 18(2): 69-79.	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
Cozzolino et al. ²²22 Cozzolino D, Esposito K, Palmiero G, De Bellis A, Furlan R, Perrotta S et al. Cardiac autonomic regulation in response to a mixed meal is impaired in obese children and adolescents: The role played by insulin resistance. J Clin Endocrinol Metab 2014; 99(9):3199–207.	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
Freitas et al. ²⁰20 Freitas IMG, Miranda JA, Mira PAC, Lanna CMM, Lima JRP, Laterza MC. Cardiac autonomic dysfunction in obese normotensive children and adolescents. Rev Paul Pediatr 2014; 32(2):244-9.	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
Kaufman et al. ²¹21 Kaufman CL, Kaiser DR, Steinberger J, Kelly AS, Dengel DR. Relationships of cardiac autonomic function with metabolic abnormalities in childhood obesity. Obesity 2007;15(5):1164 –71.	N	Y	Y	Y	Y	Y	Y	Y	Y	8
Latchman et al. ¹⁹19 Latchman PL, Mathur M, Bartels MN, Axtell RS, Meersman RE. Impaired autonomic function in normotensive obese children. Clin Auton Res 2011; 21(5):319–23.	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
Lazarova et al. ²³23 Lazarova Z, Tonhajzerova I, Trunkvalterova Z, Brozmanova A, Honzíková N, Javorka K, et al. Baroreflex sensitivity is reduced in obese normotensive children and adolescents. Can J Physiol Pharmacol 2009; 87(7):565–71.	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
Lira et al. ¹⁷17 Lira FAS, Brasileiro-Santos MS, Borba VVL, Costa MJC, Dantas PROF, Santos AC. Influência da vitamina C na modulação autonômica cardíaca no repouso e durante o exercício isométrico em crianças obesas. Rev Bras Saúde Matern Infant 2012;12(3):259-67.	N	Y	N	Y	Y	Y	Y	Y	Y	7
Martini et al. ¹⁶16 Martini G, Riva P, Rabbia F, Molini V, Ferrero GB, Cerutti F. Heart rate variability in childhood obesity. Clin Auton Res 2001;11(2):87-91.	N	Y	Y	Y	Y	Y	Y	Y	Y	8
Nagai et al. ¹⁵15 Nagai N, Matsumoto T, Kita H, Moritani T. Autonomic nervous system activity and the state and development of obesity in japanese school children. Obes Res 2003; 11(1): 25-32.	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
Paschoal et al. ¹⁸18 Paschoal MA, Trevizan PF, Scodeler NF. Variabilidade da frequência cardíaca, lípides e capacidade física de crianças obesas e não-obesas. Arq Bras Cardiol 2009; 93(3):239-46.	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
Paschoal e Pereira ¹¹11 Paschoal MA, Pereira MC. Modulação autonômica cardíaca nas posições supina e bípede em crianças não obesas, obesas e obesas mórbidas. Rev Ciênc Méd 2010; 19(1-6):33-41.	N	Y	Y	Y	Y	Y	Y	Y	Y	8
Rodriguez-Colon et al. ⁷7 Rodríguez-Colón SM, Bixler EO, Li X, Vgontzas AN, Liao D. Obesity is associated with impaired cardiac autonomic modulation in children. Int J Pediatr Obes 2011;6(2):128–34.	Y	Y	N	Y	Y	Y	Y	Y	Y	8
Tasçilar et al. ⁸8 Tasçilar ME, Yokusoglu M, Boyraz M, Baysan O, Köz C, Dündaröz R. Cardiac autonomic functions in obese children. J Clin Res Ped Endo 2011;3(2):60-4.	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
Vanderlei et al. ¹⁴14 Vanderlei LCM, Pastre CM, Júnior IFF, Godoy M. F. Índices Geométricos de Variabilidad de la Frecuencia Cardíaca em Niños Obesos y Eutróficos. Arq Bras Cardiol 2010; 95(1): 35-40.	Y	Y	Y	N	Y	Y	Y	Y	Y	8
Vanderlei et al. ¹³13 Vanderlei LCM, Pastre CM, Júnior IFF, Godoy MF. Analysis of cardiac autonomicmodulation in obese and eutrophic children. Clinics 2010; 65(8):789-92.	Y	Y	Y	Y	Y	Y	Y	Y	Y	9

Root mean square of sum of the differences between the iRR (RMSSD) (ms)
	Obese Children			Euthophic Children
Study	Mean	SD	Total	Mean	SD	Total	Weight	Standardized mean difference Fixed, 95% CI
Ancona et al.⁶6 Ancona MC, Scodeler NF, Guidi RB, Paschoal MA. Variabilidade de frequência cardíaca em crianças eutróficas e obesas nas posições supina e bípede. Rev Ciênc Méd 2009; 18(2): 69-79.	50.5	40.1	15	62.08	23.6	15	4.4%	-0.34 [-1.06. 0.38]
Vanderlei et al. ¹³13 Vanderlei LCM, Pastre CM, Júnior IFF, Godoy MF. Analysis of cardiac autonomicmodulation in obese and eutrophic children. Clinics 2010; 65(8):789-92.	27.45	12.7	56	31.92	10.34	65	17.6%	-0.39 [-0.75. -0.03]
Freitas et al.²⁰20 Freitas IMG, Miranda JA, Mira PAC, Lanna CMM, Lima JRP, Laterza MC. Cardiac autonomic dysfunction in obese normotensive children and adolescents. Rev Paul Pediatr 2014; 32(2):244-9.	56.0	28.0	31	69.0	32.0	35	9.6%	-0.43 [-0.91. 0.06]
Kaufman et al.²¹21 Kaufman CL, Kaiser DR, Steinberger J, Kelly AS, Dengel DR. Relationships of cardiac autonomic function with metabolic abnormalities in childhood obesity. Obesity 2007;15(5):1164 –71.	63.7	21.5	16	85.8	18.1	10	3.2%	-1.05 [-1.90. -0.21]
Martini et al.¹⁶16 Martini G, Riva P, Rabbia F, Molini V, Ferrero GB, Cerutti F. Heart rate variability in childhood obesity. Clin Auton Res 2001;11(2):87-91.	45.8	13.6	32	56.5	15.8	13	5.2%	-0.74 [-1.40. -0.07]
Paschoal e Pereira¹¹11 Paschoal MA, Pereira MC. Modulação autonômica cardíaca nas posições supina e bípede em crianças não obesas, obesas e obesas mórbidas. Rev Ciênc Méd 2010; 19(1-6):33-41.	63.3	39.9	10	54.8	28.5	10	3.0%	0.23 [-0.65. 1.12]
Paschoal et al.¹⁸18 Paschoal MA, Trevizan PF, Scodeler NF. Variabilidade da frequência cardíaca, lípides e capacidade física de crianças obesas e não-obesas. Arq Bras Cardiol 2009; 93(3):239-46.	64.9	36.9	15	69.9	29.8	15	4.5%	-0.15 [-0.86. 0.57]
Rodriguez-Colon et al.⁷7 Rodríguez-Colón SM, Bixler EO, Li X, Vgontzas AN, Liao D. Obesity is associated with impaired cardiac autonomic modulation in children. Int J Pediatr Obes 2011;6(2):128–34.	58.8	30.7	91	77.0	34.5	420	43.6%	-0.54 [-0.77. -0.31]
Tasçilar et al.⁸8 Tasçilar ME, Yokusoglu M, Boyraz M, Baysan O, Köz C, Dündaröz R. Cardiac autonomic functions in obese children. J Clin Res Ped Endo 2011;3(2):60-4.	73.2	37.4	32	89	45	30	9.1%	-0.38 [-0.88. 0.12]
Total (95% CI)			298			613	100%	-0.46 [-0.61. -0.31]
Heterogeneity: Chi² = 6.50, df = 8 (P = 0.59); I² = 0% Test for overall effect: Z= 6.00 (P < 0.00001)
Rest Heart Rate (HR)
	Obese Children			Euthophic Children
Study	Mean	SD	Total	Mean	SD	Total	Weight	Standardized mean difference IV, Fixed, 95% CI
Ancona et al.⁶6 Ancona MC, Scodeler NF, Guidi RB, Paschoal MA. Variabilidade de frequência cardíaca em crianças eutróficas e obesas nas posições supina e bípede. Rev Ciênc Méd 2009; 18(2): 69-79.	92.8	14.1	15	80.8	8.9	15	4.4%	0.99 [0.23. 1.75]
Cozzolino et al.²²22 Cozzolino D, Esposito K, Palmiero G, De Bellis A, Furlan R, Perrotta S et al. Cardiac autonomic regulation in response to a mixed meal is impaired in obese children and adolescents: The role played by insulin resistance. J Clin Endocrinol Metab 2014; 99(9):3199–207.	71.0	9.0	33	71.0	10.0	30	10.5%	0.00 [-0.49. 0.49]
Freitas et al.²⁰20 Freitas IMG, Miranda JA, Mira PAC, Lanna CMM, Lima JRP, Laterza MC. Cardiac autonomic dysfunction in obese normotensive children and adolescents. Rev Paul Pediatr 2014; 32(2):244-9.	78.0	9.9	31	74.0	11.0	35	10.8%	0.39 [-0.10. 0.88]
Latchman et al.²¹21 Kaufman CL, Kaiser DR, Steinberger J, Kelly AS, Dengel DR. Relationships of cardiac autonomic function with metabolic abnormalities in childhood obesity. Obesity 2007;15(5):1164 –71.	96.3	12.9	18	78.0	13.1	19	4.8%	1.42 [0.69. 2.15]
Lira et al.¹⁷17 Lira FAS, Brasileiro-Santos MS, Borba VVL, Costa MJC, Dantas PROF, Santos AC. Influência da vitamina C na modulação autonômica cardíaca no repouso e durante o exercício isométrico em crianças obesas. Rev Bras Saúde Matern Infant 2012;12(3):259-67.	83.0	2.0	21	81.0	1.0	8	3.4%	1.08 [0.22. 1.95]
Martini et al.¹⁶16 Martini G, Riva P, Rabbia F, Molini V, Ferrero GB, Cerutti F. Heart rate variability in childhood obesity. Clin Auton Res 2001;11(2):87-91.	77.1	18.1	32	76.0	10.3	13	6.2%	0.07 [-0.58. 0.71]
Nagai et al.¹⁵15 Nagai N, Matsumoto T, Kita H, Moritani T. Autonomic nervous system activity and the state and development of obesity in japanese school children. Obes Res 2003; 11(1): 25-32.	90.7	1.5	42	84.3	1.0	42	3.3%	4.97 [4.09. 5.86]
Paschoal e Pereira¹¹11 Paschoal MA, Pereira MC. Modulação autonômica cardíaca nas posições supina e bípede em crianças não obesas, obesas e obesas mórbidas. Rev Ciênc Méd 2010; 19(1-6):33-41.	81.6	9.1	10	85.1	9.7	10	3.3%	-0.35 [-1.24. 0.53]
Paschoal et al.¹⁸18 Paschoal MA, Trevizan PF, Scodeler NF. Variabilidade da frequência cardíaca, lípides e capacidade física de crianças obesas e não-obesas. Arq Bras Cardiol 2009; 93(3):239-46.	84.6	11.2	15	80.2	7.4	15	4.9%	0.47 [-0.26. 1.20]
Rodriguez-Colon et al.⁷7 Rodríguez-Colón SM, Bixler EO, Li X, Vgontzas AN, Liao D. Obesity is associated with impaired cardiac autonomic modulation in children. Int J Pediatr Obes 2011;6(2):128–34.	81.5	7.9	91	76.1	8.0	420	48.4%	0.68 [0.45. 0.91]
Total (95% CI)			308			607	100%	0.70 [0.54. 0.86]
Heterogeneity : Chi² = 114.28. df = 9 (P < 0.00001); \|² = 92% Test for overall effect: Z = 8.54 (P < 0.00001)
Percentage of adjacent iRRs greater than 50ms (pNN50)
	Obese Children			Euthophic Children
Study	Mean	SD	Total	Mean	SD	Total	Weight	Standardized mean difference IV, Fixed, 95% CI
Ancona et al.⁶6 Ancona MC, Scodeler NF, Guidi RB, Paschoal MA. Variabilidade de frequência cardíaca em crianças eutróficas e obesas nas posições supina e bípede. Rev Ciênc Méd 2009; 18(2): 69-79.	10.8	11.7	15	17.5	9.2	15	8.0%	-0.62 [-1.35. 0.12]
Vanderlei et al. ¹³13 Vanderlei LCM, Pastre CM, Júnior IFF, Godoy MF. Analysis of cardiac autonomicmodulation in obese and eutrophic children. Clinics 2010; 65(8):789-92.	9.65	10.14	56	12.08	8.91	65	33.7%	-0.25 [-0.61.0.10]
Freitas et al.²⁰20 Freitas IMG, Miranda JA, Mira PAC, Lanna CMM, Lima JRP, Laterza MC. Cardiac autonomic dysfunction in obese normotensive children and adolescents. Rev Paul Pediatr 2014; 32(2):244-9.	29.0	21.0	31	43.0	23.0	35	17.6%	-0.63 [-1.12. -0.13]
Martini et al.¹⁶16 Martini G, Riva P, Rabbia F, Molini V, Ferrero GB, Cerutti F. Heart rate variability in childhood obesity. Clin Auton Res 2001;11(2):87-91.	20.7	9.6	32	28.0	9.0	13	9.8%	-0.76 [-1.43. -0.09]
Paschoal e Pereira¹¹11 Paschoal MA, Pereira MC. Modulação autonômica cardíaca nas posições supina e bípede em crianças não obesas, obesas e obesas mórbidas. Rev Ciênc Méd 2010; 19(1-6):33-41.	15.9	11.7	10	12.3	8.3	10	5.5%	0.34 [-0.54. 1.22]
Paschoal et al.¹⁸18 Paschoal MA, Trevizan PF, Scodeler NF. Variabilidade da frequência cardíaca, lípides e capacidade física de crianças obesas e não-obesas. Arq Bras Cardiol 2009; 93(3):239-46.	15.7	10.3	15	19.1	8.9	15	8.3%	-0.34 [-1.07. 0.38]
Tasçilar et al. ⁸8 Tasçilar ME, Yokusoglu M, Boyraz M, Baysan O, Köz C, Dündaröz R. Cardiac autonomic functions in obese children. J Clin Res Ped Endo 2011;3(2):60-4.	26.8	16.4	32	34.0	13	30	17.0%	-0.48 [-0.98. 0.03]
Total (95% CI)			191			183	100%	-0.41 [-0.62. -0.20]
Heterogeneity : Chi² = 5.70. df = 6 (P = 0.46); \|² = 0% Test for overall effect: Z = 3.87 (P = 0.0001)
Standard deviations of iRRs in milliseconds (SDNN)
	Obese Children			Euthophic Children
Study	Mean	SD	Total	Mean	SD	Total	Weight	Standardized mean difference IV, Fixed, 95% CI
Vanderlei et al. ¹³13 Vanderlei LCM, Pastre CM, Júnior IFF, Godoy MF. Analysis of cardiac autonomicmodulation in obese and eutrophic children. Clinics 2010; 65(8):789-92.	37.18	26,26	56	42.58	10.48	65	19.8%	-0.28 [-0.64. 0.08]
Freitas et al.²⁰20 Freitas IMG, Miranda JA, Mira PAC, Lanna CMM, Lima JRP, Laterza MC. Cardiac autonomic dysfunction in obese normotensive children and adolescents. Rev Paul Pediatr 2014; 32(2):244-9.	49.0	21,0	31	55.0	21.0	35	10.8%	-0.28 [-0.77. 0.20]
Martini et al.¹⁶16 Martini G, Riva P, Rabbia F, Molini V, Ferrero GB, Cerutti F. Heart rate variability in childhood obesity. Clin Auton Res 2001;11(2):87-91.	129.4	27,6	32	149	51.0	13	6.0%	-0.54 [-1.19. 0.12]
Paschoal et al.¹⁸18 Paschoal MA, Trevizan PF, Scodeler NF. Variabilidade da frequência cardíaca, lípides e capacidade física de crianças obesas e não-obesas. Arq Bras Cardiol 2009; 93(3):239-46.	64.9	28,7	15	68.6	23.7	15	5.0%	-0.14 [-0.85. 0.58]
Rodriguez-Colon et al. ⁷7 Rodríguez-Colón SM, Bixler EO, Li X, Vgontzas AN, Liao D. Obesity is associated with impaired cardiac autonomic modulation in children. Int J Pediatr Obes 2011;6(2):128–34.	79.2	25,0	91	98.0	27.0	420	48.1%	-0.70 [-0.93. -0.47]
Tasçilar et al. ⁸8 Tasçilar ME, Yokusoglu M, Boyraz M, Baysan O, Köz C, Dündaröz R. Cardiac autonomic functions in obese children. J Clin Res Ped Endo 2011;3(2):60-4.	137.8	35,1	32	142	29	30	10.3%	-0.13 [-0.63. 0.37]
Total (95% CI)			257			578	100%	-0.48 [-0.64. -0.32]
Heterogeneity: Chi² = 8.32. df = 5 (P = 0.14); \|² = 40% Test for overall effect: Z = 5.83 (P < 0.00001)

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[1] Grasiely Faccin Borges, Centro de Formação em Ciências da Saúde da Universidade Federal do Sul da Bahia-UFSB, Campus Paulo Freire – Teixeira de Freitas, Praça Joana Angélica, 250, bairro São José, Teixeira de Freitas – BA, CEP: 45988-058, Brasil. Email: grasiely.borges@gmail.com