Effect of physical training on the blood pressure of adolescents with obesity

Abstracts

OBJETIVO: Descrever, por meio de uma revisão sistemática, os efeitos do treinamento físico sobre a pressão arterial em adolescentes com obesidade. FONTES DE DADOS: Recorreu-se à revisão sistemática de ensaios clínicos randomizados que analisaram o efeito do treinamento físico sobre a pressão arterial de adolescentes obesos, publicados em periódicos indexados nas bases de dados PubMed/Medline, Lilacs, SciELO e ISI Web of KnowledgeSM. Foram incluídos os estudos que avaliaram adolescentes publicados até 2010, e que possuíam Grupo Controle. SÍNTESE DOS DADOS: Oito estudos atenderam aos critérios de inclusão. Dois deles utilizaram exercícios de força combinados com aeróbios, enquanto seis empregaram apenas os aeróbios. Cinco estudos utilizaram intervenções complementares, sendo a nutricional a mais frequente. Quatro estudos observaram redução da pressão arterial sistólica no Grupo Exercício comparado ao Controle. Nesses quatro estudos, além da redução da pressão arterial, notou-se diminuição da massa corpórea. Todos aqueles que verificaram redução da pressão arterial utilizaram 12 a 24 semanas de exercícios aeróbios, três a seis sessões semanais, com duração de 50 a 90 minutos e intensidade entre 55 e 75% da frequência cardíaca máxima. CONCLUSÕES: O efeito do treinamento físico na pressão arterial de adolescentes obesos é controverso. A redução da pressão arterial parece ocorrer com programas de treinamento aeróbios que promovam também a redução da massa corpórea.

adolescentes; obesidade; pressão arterial; exercício

REVIEW

Effect of physical training on the blood pressure of adolescents with obesity

Efecto del entrenamiento físico en la presión arterial de adolescentes con obesidad

Breno Quintella Farah^I; Mariana de Freitas Berenguer^II; Wagner Luiz do Prado^III; Crivaldo Gomes C. Júnior^IV; Raphael Mendes R. Dias^V

Instituição:Escola Superior de Educação Física da Universidade de Pernambuco (ESEF/UPE), Recife, PE, Brasil

^IMestrando em Hebiatria pela UPE, Recife, PE, Brasil

^IIGraduação em Bacharelado em Educação Física pela UPE, Recife, PE, Brasil

^IIIDoutor em Nutrição pela Universidade Estadual de São Paulo "Júlio de Mesquita Filho" (Unesp); Professor Adjunto da UPE, Recife, PE, Brasil

^IVDoutor em Educação Física pela Universidade de São Paulo (USP); Docente do Curso de Educação Física da Universidade Estadual de Londrina (UEL), Londrina, PR, Brasil

^VDoutor em Saúde Pública pela USP; Professor Adjunto da UPE, Recife, PE, Brasil

Endereço para correspondência

ABSTRACT

OBJECTIVE: To systematically review the results of studies that analyzed the effects of physical training on the blood pressure of obese adolescents.

DATA SOURCES: A systematic review of randomized clinical trials was performed and examined the effect of physical training on the blood pressure of obese adolescents, published in journals indexed at PubMed/Medline, Lilacs, SciELO, and ISI Web of knowledge^SM databases. Studies that evaluated adolescents published until 2010 and that had a Control Group were included.

DATA SYNTHESIS: Eight studies met the inclusion criteria. Two of them used strength exercises combined with aerobics, while six used only aerobics. Five studies used complementary intervention, especially nutritional. Four studies found decreased systolic blood pressure in the Training Group compared to Controls, together with the reduction in body mass. All studies that found a reduction in systolic blood pressure used aerobic exercises from 12 to 24 weeks three to six times per week, lasting 50 to 90 minutes, and with intensity between 55 and 75% at the maximum heart rate.

CONCLUSIONS: The effect of physical training on the systolic blood pressure of obese adolescents is controversial. However, the reduction in systolic blood pressure seems to occur with aerobic training programs, that also reduce body mass.

Key-words: adolescents; obesity; blood pressure; exercise.

RESUMEN

OBJETIVO: Describir, mediante una revisión sistemática, los efectos del entrenamiento físico sobre la presión arterial en adolescentes con obesidad.

FUENTES DE DATOS: Se recurrió a la revisión sistemática de ensayos clínicos aleatorios que analizaron el efecto del entrenamiento físico sobre la presión arterial de adolescentes obesos, publicados en periódicos indexados en las bases de datos PubMed/MedLine, LILACS, SciELO e ISI Web of knowledgeSM. Se incluyeron los estudios que evaluaron a adolescentes, publicados hasta el año de 2010 y que poseían grupo control.

SÍNTESIS DE LOS DATOS: Ocho estudios atendieron a los criterios de inclusión. Dos de ellos utilizaron ejercicios de fuerza combinados con aeróbicos, mientras que seis emplearon solamente ejercicios aeróbicos. Cinco estudios utilizaron intervenciones complementarias, siendo la intervención nutricional la más frecuente. Cuatro estudios observaron reducción de la presión arterial sistólica en el grupo ejercicio comparado al control. En esos cuatro estudios, además de la reducción de la presión arterial, se notó disminución de la masa corporal. Todos los estudios que verificaron reducción de la presión arterial utilizaron de 12 a 24 semanas de ejercicios aeróbicos. El programa de entrenamiento tuvo lugar con tres a seis sesiones semanales con duración de 50 a 90 minutos e intensidad entre 55 y 75% de la frecuencia cardíaca máxima.

CONCLUSIONES: El efecto del entrenamiento físico en la presión arterial de adolescentes obesos es controvertido. Sin embargo, la reducción de la presión arterial parece ocurrir con programas de entrenamiento aeróbicos que promueven también la reducción de la masa corporal.

Palabras clave: adolescentes; obesidad; presión arterial; ejercicio.

Introduction

Obesity is one of the most prevalent diseases among adolescents⁽¹⁾, ranging from 6 to 12% in Brazil, depending on the geographic location^(2-5). Hypertension, the main risk factor for cardiovascular disease, is also highly prevalent in adolescents, mainly the obese ones^(6-13). A recent study⁽⁹⁾ showed that the prevalence of hypertension is six fold higher in obese adolescents compared to normal weight children. Thus, the treatment of these adolescents should include weigh control, as well as the reduction of blood pressure^(10,17-22).

Physical training is considered an important component of obesity treatment in adolescents. Several studies have shown that adolescents who undergo systematic physical training show improvement in physical fitness⁽²³⁾, body composition⁽¹⁴⁾ and decrease in inflammatory markers^(24,25). In contrast, the effects of physical training on the blood pressure of this population remain controversial^{(20-22,26-32)}. While some studies have observed a reduction^{(19,28,30,31)} in systolic blood pressure, in others it remained unchanged^(20-22,29). Studies that analyzed the effects of physical training in diastolic and mean blood pressure have also shown controversial results^{(19-22,28-31)}.

In this context, it is necessary to summarize the data about the effects of physical training on the blood pressure of obese adolescents, aiming to identify the factors related to such differences. Therefore, this study aimed to analyze, using a systematic review, the effects of physical training on the blood pressure of obese adolescents.

Methods

The main outcome of this review was the change in the blood pressure of obese adolescents after a physical training program. We performed a systematic review of the original studies published in journals indexed in PubMed/MedLine (National Library of Medicine), LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde), SciELO (Scientific Electronic Library Online) and ISI Web of knowledge^SM electronic databases, which analyzed the effects of physical training on the blood pressure of obese adolescents.

The keywords used in the electronic research were defined in consultation to the Medical Subject Headings (MeSH) on the U.S. National Library of Medicine (NLM) website and to the DeCS – Describers in Health Sciences (Descritores em Ciências da Saúde) in the Health Virtual Library (Biblioteca Virtual em Saúde – BVS). The keywords were divided into four blocks, and then combined, as shown in Figure 1.

The electronic search in the databases was performed using the combination of the keywords and the application of limits, with the inclusion of studies that: evaluated subjects between 10 and 18 years old; were published up to 2010; were performed in humans; were randomized clinical trials; and were controlled.

By reading the titles and abstracts retrieved in the first search, we included studies that met the following criteria: the sample was constituted of obese adolescents, regardless of whether the studies included other age groups; the blood pressure was measured; and the study included a non exercise control group.

In the following step, we performed the full reading of the articles and data extraction. In this step, besides the outcome, we also extracted the data that could have affected the main outcome, such as the sample characteristics, the body mass, the exercise protocol and complementary interventions. We also performed the analysis of the studies quality using the PEDro score⁽³³⁾. This score consists of 11 questions, with scores ranging from zero (minimum) to ten (maximum).

All the steps (electronic search in the databases, selection and evaluation of the potential studies, data extraction and analysis of the studies quality) were performed by two independent investigators, and the results of each phase were compared by a third investigator, who evaluated the agreement between the pairs. If disagreements were found, the third investigator was responsible for the final analysis.

Results

We identified 106 studies (Figure 2) in the PubMed/MedLine database, 103 in LILACS, 77 in ISI and none in SciELO. From these, only 15 evaluated the effects of physical training on the cardiovascular variables of obese adolescents^{(17-22,26-31,34-36)}. Four of these studies were excluded for the lack of a control group^{(26,27,35,36)} and three others for not evaluating the effects of physical training on blood pressure^(17,18,34).

Table 1 shows the main characteristics of the studies included in this review. From the eight studies included, six were published since 2000^{(19-22,28,29)}. The sample size ranged from 19 to 443 adolescents aging from 10 to 17 years old. The mean body mass ranged from 29.2 to 34.4kg/m². The PEDPro score ranged from 4 to 7.

Five studies used some kind of complementary intervention^(19,28-31), with the dietary intervention being the most common (Table 2). The duration of training ranged from 8 to 48 weeks. Regarding the exercises protocol, two studies used strength exercises combined with aerobic exercises^(21,22), while six used aerobic exercises only. Three of these studies combined walking with sporting activities^(22,28,30).Most studies used a three weekly sessions schedule lasting from 40 to 90 minutes each, with intensities from 55 to 95% of the maximum heart rate.

Table 3 shows the results of the effects of training on blood pressure. Four studies observed a decrease in the systolic blood pressure in the training group compared with the control group^(19,28-30), while four other studies did not show any difference^(20-22,29). Two studies ^(29,30) observed a decrease in the diastolic pressure and one study⁽³⁰⁾showed a decrease in the mean blood pressure in the training group when compared with the control group. The four studies that showed a decrease in the systolic blood pressure also found a decrease in body mass.

Discussion

The main findings of this study were: the effects of physical training on the blood pressure of obese adolescents are controversial, the decrease in the blood pressure resulting from physical training seems to occur concomitantly with the reduction in the body mass; and the studies that observed a decrease in the blood pressure with physical training used an exercise schedule consisting of three to six weekly sessions of aerobic exercises lasting from 50 to 90 minutes each, with intensity of 55 to 75% of the maximum heart rate, and training duration ranging from 12 to 24 weeks.

For this review, we performed a literature search in the PubMed/MedLine, LILACS, ISI and SciELO databases, which represent the main sources of original scientific data in health sciences. The search showed that articles on the theme were only identified at PubMed/MedLine and ISI. These results emphasize that original information on the effects of physical training on the blood pressure of obese adolescents are not conveyed in the Latin American literature, so that professionals who are interested in obtaining information on the subject must necessarily consult the databases in the English language.

The results of the studies that analyzed the effects of physical training on the blood pressure of obese adolescents showed great controversy. Of the eight studies that evaluated the effects of physical training on the systolic pressure, only four found a significant decrease. Likewise, only some of the studies that evaluated the effects on the diastolic and mean pressure showed a reduction of these variables in response to physical training. This controversy seems to be directly related to changes in the body mass resulting from physical training. Actually, all the studies that observed a reduction in the systolic blood pressure also showed a reduction in the body mass, and in two of them^(30,31) the changes in both variables were correlated.

The decrease in blood pressure mediated by the reduction of body mass can be explained by mechanical (lesser mechanical compression of the fat mass on the blood vessels), metabolic (reduction of leptin levels⁽³⁷⁾ and insulin resistance⁽³⁸⁾), inflammatory (decrease in pro-inflammatory agents⁽³⁹⁾) and neural (decrease in the sympathetic nerve activity⁽⁴⁰⁾) factors. These results emphasize the importance of the reduction of the body mass in the decrease in blood pressure, which reinforces the importance of the dietary intervention in the treatment of the obese adolescent^(41-43).

Based on the summary our findings, we identified a great variability in the training protocols used, which may also have contributed to the controversial findings. From the eight studies included, for instance, five used aerobic exercises only, while two used a combination of aerobic training with strength exercises, and only one applied an interval aerobic training. The intensity ranged from 55 to 95% of the maximum heart rate, and the duration of each session ranged from 40 to 90 minutes. It is suggested that the reduction in blood pressure mediated by the physical training results from several factors, such as: improvement in the endothelial function⁽²¹⁾, reduction in the cardiac sympathetic tone^(44-46), increased sensitivity of the cardiovascular reflexes⁽⁴⁷⁾ and decrease in leptin levels^(48-50), among others. However, these factors seem less important for the decrease in blood pressure then the reduction of the body mass, since not all the studies that used physical training showed a decrease in blood pressure.

The analysis of the study protocols that found a reduction in blood pressure shows some common points: all of them used at least three sessions of aerobic exercises per week, lasting from 50 to 90 minutes, with intensities from 55 to 75% of the maximum heart rate. Furthermore, no differences in blood pressure were observed in the studies with training duration less than 12 weeks. Therefore, training programs that aim the reduction in the blood pressure of obese adolescents should be based on these training protocols.

Some limitations of the present study should be considered. The literature search was performed in journals indexed in the PubMed/MedLine, LILACS and ISI databases only. It is, thus, possible that some studies on the theme may have not been included. It is noteworthy, however, that the databases used in our study are the most used for searching articles in both Portuguese and English languages. Also, the literature search did not include the databases of theses and dissertations, which could possibly have limited the number of studies included. Finally, the search used only keywords in Portuguese and English only, and studies published in other languages were not included.

The results of this review indicate that there is no consensus in the literature about the cardiovascular effects of physical training on the blood pressure of obese adolescents. Nevertheless, it was possible to identify that studies that showed a decrease in the blood pressure also observed a reduction in the body mass, using protocols of three to six weekly sessions of aerobic exercises lasting from 50 to 90 minutes, with intensities from 55 to 75% of the maximum heart rate, and duration of training ranging from 12 to 24 weeks. In spite of these results, one should take into account that that the well planned physical training should be stimulated in this population regardless the blood pressure response in the view of the other positive effects related to training on the reduction of cardiovascular risks.

References

• ¹
  World Health Organization - WHO. Global strategy on diet, physical activity and health. Geneva: WHO; 2008.
• 2. Cavalcanti CB, Barros MV, Menêses AL, Santos CM, Azevedo AM, Guimarães FJ. Abdominal obesity in adolescents: prevalence and association with physical activity and eating habits. Arq Bras Cardiol 2010;94:350-6.
• 3. De Moraes AC, Fadoni RP, Ricardi LM, Souza TC, Rosaneli CF, Nakashima AT et al Prevalence of abdominal obesity in adolescents: a systematic review. Obes Rev 2011;12:69-77.
• 4. Terres NG, Pinheiro RT, Horta BL, Pinheiro KA, Horta LL. Prevalence and factors associated to overweight and obesity in adolescents. Rev Saude Publica 2006;40:627-33.
• 5. Balaban G, Silva GA. Overweight and obesity prevalence in children and adolescents from a private school in Recife. J Pediatr (Rio J) 2001;77:96-100.
• 6. Davy KP, Hall JE. Obesity and hypertension: two epidemics or one? Am J Physiol Regul Integr Comp Physiol 2004;286:R803-13.
• 7. Gomes BM, Alves JG. Prevalence of high blood pressure and associated factors in students from public schools in Greater Metropolitan Recife, Pernambuco State, Brazil, 2006. Cad Saude Publica 2009;25:375-81.
• 8. Hall JE, da Silva AA, do Carmo JM, Dubinion J, Hamza S, Munusamy S et al Obesity-induced hypertension: role of sympathetic nervous system, leptin, and melanocortins. J Biol Chem 2010;285:17271-6.
• 9. Obarzanek E, Wu CO, Cutler JA, Kavey RE, Pearson GD, Daniels SR. Prevalence and incidence of hypertension in adolescent girls. J Pediatr 2010;157:461-7.
• 10. Sociedade Brasileira de Cardiologia. VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2010;95 (Suppl 1):1-51.
• 11. Iwashima S, Nakagawa Y, Ishikawa T, Satake SS, Nagata E, Ohzeki T. Abdominal obesity is associated with cardiovascular risk in Japanese children and adolescents. J Pediatr Endocrinol Metab 2011;24:51-4.
• 12. Katona E, Zrínyi M, Lengyel S, Komonyi E, Paragh G, Zatik J et al The prevalence of adolescent hypertension in Hungary - the Debrecen hypertension study. Blood Pressure 2011;20:134-9.
• 13. Christofaro DG, Casonatto J, Fernandes RA, Reichert FF, Lock MR, Guariglia DA et al High blood pressure in adolescents of high economic status. Rev Paul Pediatr 2010;28:23-8.
• 14. Prado WL, Siegfried A, Dâmaso AR, Carnier J, Piano A, Siegfried W. Effects of long-term multidisciplinary inpatient therapy on body composition of severely obese adolescents. J Pediatr (Rio J) 2009;85:243-8.
• 15. Taylor RW, Mcauley KA, Williams SM, Barbezat W, Nielsen G, Mann JI. Reducing weight gain in children through enhancing physical activity and nutrition: the APPLE project. Int J Pediatr Obes 2006;1:146-52.
• 16. Nowicka P, Höglund P, Pietrobelli A, Lissau I, Flodmark CE. Family Weight School treatment: 1-year results in obese adolescents. Int J Pediatr Obes 2008;3:141-7.
• 17. Mitchell BM, Gutin B, Kapuku G, Barbeau P, Humphries MC, Owens S et al Left ventricular structure and function in obese adolescents: relations to cardiovascular fitness, percent body fat, and visceral adiposity, and effects of physical training. Pediatrics 2002;109:E73-3.
• 18. Naylor LH, Watts K, Sharpe JA, Jones TW, Davis EA, Thompson A et al Resistance training and diastolic myocardial tissue velocities in obese children. Med Sci Sports Exerc 2008;40:2027-32.
• 19. Park TG, Hong HR, Lee J, Kang HS. Lifestyle plus exercise intervention improves metabolic syndrome markers without change in adiponectin in obese girls. Ann Nutr Metab 2007;51:197-203.
• 20. Tjonna AE, Stolen TO, Bye A, Volden M, Slordahl SA, Odegard R et al Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents. Clin Sci (Lond) 2009;116:317-26.
• 21. Watts K, Beye P, Siafarikas A, Davis EA, Jones TW, O'Driscoll G et al Exercise training normalizes vascular dysfunction and improves central adiposity in obese adolescents. J Am Coll Cardiol 2004;43:1823-7.
• 22. Wong PC, Chia MY, Tsou IY, Wansaicheong GK, Tan B, Wang JC et al Effects of a 12-week exercise training programme on aerobic fitness, body composition, blood lipids and C-reactive protein in adolescents with obesity. Ann Acad Med Singapore 2008;37:286-93.
• 23. Sabia RV, Santos JE, Ribeiro RP. Efeito da atividade física associada à orientação alimentar em adolescentes obesos: comparação entre o exercício aeróbio e anaeróbio. Rev Bras Med Esporte 2004;10:349-55.
• 24. Gutin B, Ramsey L, Barbeau P, Cannady W, Ferguson M, Litaker M et al Plasma leptin concentrations in obese children: changes during 4-mo periods with and without physical training. Am J Clin Nutr 1999;69:388-94.
• 25. Dâmaso AR, Tock L, Tufik S, Prado WL, Stella SG, Fisberg M et al Multidisciplinary treatment reduces visceral adiposity tissue, leptin, ghrelin and the prevalence of non-alcholic fat liver disease (NAFLD) in obese adolescents. Rev Bras Med Esporte 2006;12:263-7.
• 26. Brownell KD, Kelman JH, Stunkard AJ. Treatment of obese children with and without their mothers: changes in weight and blood pressure. Pediatrics 1983;71:515-23.
• 27. Kelishadi R, Hashemipour M, Sarrafzadegan N, Mohammadifard N, Alikhasy H, Beizaei M et al Effects of a lifestyle modification trial among phenotypically obese metabolically normal and phenotypically obese metabolically abnormal adolescents in comparison with phenotypically normal metabolically obese adolescents. Matern Child Nutr 2010;6:275-86.
• 28. Meyer AA, Kundt G, Lenschow U, Schuff-Werner P, Kienast W. Improvement of early vascular changes and cardiovascular risk factors in obese children after a six-month exercise program. J Am Coll Cardiol 2006;48:1865-70.
• 29. Reinehr T, Kleber M, Toschke AM. Lifestyle intervention in obese children is associated with a decrease of the metabolic syndrome prevalence. Atherosclerosis 2009;207:174-80.
• 30. Rocchini AP, Katch V, Anderson J, Hinderliter J, Becque D, Martin M et al Blood pressure in obese adolescents: effect of weight loss. Pediatrics 1988;82:16-23.
• 31. Rocchini AP, Katch V, Schork A, Kelch RP. Insulin and blood pressure during weight loss in obese adolescents. Hypertension 1987;10:267-73.
• 32. Kelley GA, Kelley KS, Tran ZV. The effects of exercise on resting blood pressure in children and adolescents: a meta-analysis of randomized controlled trials. Prev Cardiol 2003;6:8-16.
• 33. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003;83:713-21.
• 34. Adamo KB, Rutherford JA, Goldfield GS. Effects of interactive video game cycling on overweight and obese adolescent health. Appl Physiol Nutr Metab 2010;35:805-15.
• 35. Akimoto-Gunther L, Hubler M, Santos M, Carolino I, Sonoo N, Botti B et al Effects of re-education in eating habits and physical activity on the lipid profile of obese teenagers. Clin Chem Lab Med 2002;40:460-2.
• 36. Kelishadi R, Hashemi M, Mohammadifard N, Asgary S, Khavarian N. Association of changes in oxidative and proinflammatory states with changes in vascular function after a lifestyle modification trial among obese children. Clin Chem 2008;54:147-53.
• 37. Chu NF, Wang DJ, Shieh SM. Obesity, leptin and blood pressure among children in Taiwan: the Taipei children's heart study. Am J Hypertens 2001;14:135-40.
• 38. Lurbe E, Torro I, Aguilar F, Alvarez J, Alcon J, Pascual JM et al Added impact of obesity and insulin resistance in nocturnal blood pressure elevation in children and adolescents. Hypertension 2008;51:635-41.
• 39. Syrenicz A, Garanty-Bogacka B, Syrenicz M, Gebala A, Dawid G, Walczak M. Relation of low-grade inflammation and endothelial activation to blood pressure in obese children and adolescents. Neurol Endocrinol Lett 2006;27:459-64.
• 40. Kaufman CL, Kaiser DR, Steinberger J, Dengel DR. Relationships between heart rate variability, vascular function, and adiposity in children. Clin Auton Res 2007;17:165-71.
• 41. Stabouli S, Papakatsika S, Kotsis V. The role of obesity, salt and exercise on blood pressure in children and adolescents. Expert Rev Cardiovasc Ther 2011;9:753-61.
• 42. Randall OS, Kwagyan J, Huang Z, Xu S, Ketete M, Maqbool AR. Effect of diet and exercise on pulse pressure and cardiac function in morbid obesity: analysis of 24-hour ambulatory blood pressure. J Clin Hypertens (Greenwich) 2005;7:455-63.
• 43. Roberts CK, Vaziri ND, Barnard RJ. Effect of diet and exercise intervention on blood pressure, insulin, oxidative stress, and nitric oxide availability. Circulation 2002;106:2530-2.
• 44. Hautala AJ, Kiviniemi AM, Tulppo MP. Individual responses to aerobic exercise: the role of the autonomic nervous system. Neurosci Biobehav Rev 2009;33:107-15.
• 45. Malpas SC. Sympathetic nervous system overactivity and its role in the development of cardiovascular disease. Physiol Rev 2010;90:513-57.
• 46. Fisher JP, Paton JF. The sympathetic nervous system and blood pressure in humans: implications for hypertension. J Hum Hypertens. 2011. In press.
• 47. Heffernan KS, Collier SR, Kelly EE, Jae SY, Fernhall B. Arterial stiffness and baroreflex sensitivity following bouts of aerobic and resistance exercise. Int J Sports Med 2007;28:197-203.
• 48. Paolisso G, Manzella D, Montano N, Gambardella A, Varricchio M. Plasma leptin concentrations and cardiac autonomic nervous system in healthy subjects with different body weights. J Clin Endocrinol Metab 2000;85:1810-4.
• 49. Eikelis N, Schlaich M, Aggarwal A, Kaye D, Esler M. Interactions between leptin and the human sympathetic nervous system. Hypertension 2003;41:1072-9.
• 50. Fisher JS, van Pelt RE, Zinder O, Landt M, Kohrt WM. Acute exercise effect on postabsorptive serum leptin. J Appl Physiol 2001;91:680-6.

Publication Dates

• Publication in this collection
  04 Jan 2013
• Date of issue
  Dec 2012

History

• Received
  30 Oct 2011
• Accepted
  27 Feb 2012