Evidence-Based Healthcare & Public Health (2005) 9, 282–283 COMMENTARY Structured exercise is too little too late for an obese child – we should be encouraging healthy lifestyles Iain Buchan*, Peter Bundred y , Gareth Stratton z * Senior Lecturer in Public Health, The University of Manchester y Reader in Primary Care, The University of Liverpool z Reader in Paediatric Exercise Science, Liverpool John Moores University, UK In their literature review on the long-term effects of promoting physical activity in children (doi:10.1016/j.ehbc.2005.05.004), Bazian rightly conclude that increased levels of activity in children of normal weight helps to control exces- sive weight gain. In obese children, however, this is not the case: most of the studies Bazian reviewed showed little or no weight loss after structured exercise programmes. Despite a lack of properly controlled studies and sufficiently long follow-up periods, research on the effects of physical activity in obesity shows that physical activity does not cure obesity in children, but it can help to reduce obesity in the context of lifestyle change. Epstein showed behavioural inter- ventions to be more effective than dietary mea- sures, 1 and reduction of sedentary behaviour to be more effective than structured exercise 2 : in other words, lifestyle/maintenance approaches are more effective than therapeutic approaches. Further support for a lifestyle approach is provided by studies that show combined interven- tions to be more effective than focused alterna- tives. 3 This applies both to the prevention of obesity in whole populations and to the manage- ment of obesity. 4 In addition, the effectiveness of such interventions might better be assessed using measures of central adiposity than body mass index (BMI). 5 With the limited evidence to date, structured exercise is unlikely to be the answer in combating obesity in children. From both clinical and public health perspectives, the physical activity compo- nent of anti-obesity interventions should be about lasting behaviour change, promoting physical ac- tivity and reducing sedentary behaviour. Reduced fatness is not the only important out- come of regular structured exercise in obese children. Two recent studies have shown that regular exercise in this group improves vascular tone and may be an important factor in reducing the long-term risk of atherosclerosis. Watts and colleagues examined the effects of exercise on vascular endothelial function in fourteen children with a mean BMI of 30 compared with a group of seven lean controls. 6 After an 8-week structured exercise programme there was no change in BMI, but flow-mediated dilation of the brachial artery, a proxy for early atherosclerosis, improved signifi- cantly. Ribeiro and colleagues found that a combi- nation of diet and a structured exercise, but not diet alone, reduced blood pressure and improved the vasodilatory response in a group of obese children. 7 ARTICLE IN PRESS www.elsevier.com/locate/ebhph 1744-2249/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ehbc.2005.05.006