Differences in the absolute muscle strength and power of children and adolescents with overweight or obesity. A systematic review

doi:10.21203/rs.3.rs-3131775/v1

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Differences in the absolute muscle strength and power of children and adolescents with overweight or obesity. A systematic review

https://doi.org/10.21203/rs.3.rs-3131775/v1

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published 19 Sep, 2023

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This study aimed to describe absolute muscle strength and power in children and adolescents with obesity, overweight and normal weight, and the assessment tests and tools used. We retrieved observational studies from MEDLINE (PubMed), TripDataBase, Epistemonikos, EBSCO essentials, NICE, SCOPUS, and LILACs up to February 2023. In addition, we recovered data from studies with at least three comparison groups (obesity, overweight, normal weight) and with a description of the absolute muscle strength and power and the assessment tests and instruments used. The methodologic quality of the studies was assessed with the Joanna Briggs checklist, and the review was carried out using the PRISMA 2020 methodology. Eleven studies with 13, 451 participants aged 6 to 18 were included; upper limb absolute muscle strength was higher in overweight and obese compared to normal weight, but not when loading their body weight. In addition, lower limb absolute muscle strength was significantly lower in obese participants than in normal weight, regardless of age and gender. The most used tools to measure the absolute muscle strength of the upper limbs were the grip dynamometers and push-up exercises. In contrast, different jump tests were used to measure the power of the lower limbs. There are great differences in muscle strength and power between overweight or obese children and adolescents and those with normal weight. Therefore, it is recommended to use validated tests, preferably that assess strength through the load of the patient's body weight, either of the upper or lower limbs, for greater evaluation objectivity that facilitates the management of these children and adolescents.

Absolute muscle strength

power

assessment instruments

muscle tests

obesity

overweight

Obesity and overweight are global health problems that affect children and adolescents;[1, 2] In 2020, the World Health Organization reported that 39 million children under five years of age and over 340 million children and adolescents between 5 and 19 years lived with overweight or obesity.[3]

Obesity and overweight have been associated with several adult diseases, leading to disability and decreased quality of life.[4] Besides, there are reports in the literature that have described a higher prevalence of musculoskeletal disorders in overweight or obese children compared to children with a normal weight (16% vs 14.1%; OR 95% CI = 1.16 (0.84–1.61).[5] The above has been explained because visceral adipose tissue hypertrophy contributes to muscle dysfunction, mainly through the dysregulated production of adipokines; for this reason, the muscle cell is less efficient when executing signalling functions.[6] Obesity also increases the secretion of adiponectin, and the production of inflammatory mediators, while decreasing the synthesis of contractile proteins in the myotubes of muscle fibres.[7]

Furthermore, there is growing evidence showing the effects of obesity on skeletal muscle function, such as [8] impairment in oxidative capacity,[9] abnormal muscle fibre organization,[10] interrupting the calcium cycle,[11] inducing easy fatigue,[7] and a decline in contractile function[12] and the change of slow-twitch fibres to fast-twitch ones. [13]

On the other hand, clinical studies on the effects of obesity on muscle size and function have shown that muscle torque, and power, in people with obesity are higher than those of normal weight. [14] Obesity has also been associated with reduced maximum muscle strength, affecting mainly the function of antigravity muscles, leading to reduced mobility.[15]

Additionally, muscle strength is considered an essential factor in the development of children and adolescents, which is necessary to carry out daily life activities such as self-care, walking, or running, which are essential to facilitate adequate social interaction and prevent diseases in adulthood.[16–19]

Even though the evaluation of muscle strength is necessary due to the above, most of the studies in children and adolescents are carried out with tests used in adults, which are "adapted" and rarely validated, which makes it difficult to know precisely the degree of impairment of muscle strength and power in overweight and obese children. This review aimed to describe absolute muscle strength and power in children and adolescents with obesity or overweight, as well as the tests and instruments used currently for evaluation.

2.1 Data sources

This review was carried out following the question frame PEOS (Patient; Exposure, Outcome, Study): P = Participants aged 6–18 years, E = obesity or overweight or normal weight, O = muscle strength, muscle power, and S = Observational studies. This review was not registered in any international database of prospectively systematic reviews, but it was carried out through the PRISMA methodology. An additional file shows the description of the assessment test considered in this review; see Supplementary Material Annex 1.

Initially, we developed different search strategies in the electronic database MEDLINE (PubMed) using the MeSH terms: "child,” “obesity,” “muscle strength,” and ”physical fitness,” and through the search process, resulted in this final search strategy: “overweight AND obesity AND child AND muscular AND perform AND muscle strength AND physical fitness AND fitness,” and then we adapted this strategy to the different search engines; TripDataBase, Epitemonikos, EBSCO essentials, NICE, SCOPUS, OVID, ScienceDirect, BVS and LILACs (Fig. 1). An additional file shows the search strategy used to identify studies; see Supplementary Material Annex 2.

2.2 Study selection

We included observational articles that studied patients with overweight and/or obesity with at least two comparison groups (obese vs no obese, obese vs overweight, obese, and overweight); and with the description of the assessment tests and instruments used. Children and adolescents with normal weight were considered as a reference group, and underweight ones were not considered. Studies that could be retrieved in full text and published in Spanish and English without limits in the search period were also included. Studies that included patients with endogenous causes of obesity and those without a detailed description of the groups evaluated nor of the test used to determine muscle strength or power were excluded. We also did not include studies that reported their results exclusively through the statistical significance of regression coefficients, cohort studies, case controls, or clinical trials. We do not seek contact with the authors of included studies when retrieving the required information.

We performed another search within the references of the articles selected to identify additional studies. The searching strategy was updated in February 2023, and four more studies were identified by title and abstract but were excluded due to; a different approach; they did not report muscle strength and power data.

Five researchers (JLAA, MKK, MEOC, JOLT, KVM) independently evaluated the selected articles, reviewed the titles, abstracts, and a sixth reviewer (CGC) resolved the conflicts. The duplicated articles and those not meeting the inclusion criteria were excluded. Once the review of titles and abstracts by the reviewers was completed, the full texts were reviewed, and the reasons for being chosen were recorded. The data extraction and management from the included studies adhered to the recommendations of the PRISMA 2020 expanded checklist. [20]

2.3 Data Extraction

The data extraction form included the description of the following characteristics: participants’ age, sex, country, sample size comparison groups (obese vs no obese, obese vs overweight, obese, and overweight); assessment tests and instruments used and parameters evaluated; strength, power, physical activity level, balance, cardiovascular capacity, coordination flexibility, agility, velocity, although the main focus was on absolute muscular strength and power. We defined muscular strength as the force generated by muscle contraction and can be measured during isometric, isotonic, or isokinetic contraction. Muscular power was defined as the work rate, reflecting the force exerted per unit of time.[21] Data extraction was performed independently by five researchers (JLAA, MEOC, JOLT KVM, MKK), which was corroborated by a sixth researcher (CGC). The extracted information was recorded in an Excel file for subsequent synthesis.

2.3.1 Data analysis

Data from all included studies were summarised and described, but we did not make a comparison between studies due to the great diversity in the data reporting and assessment instruments. We also decided not to perform a meta-analysis of the data obtained in this review for the same reason.

2.3.2 Quality assessment

We used the Joanna Briggs Institute Critical Appraisal tools in JBI Systematic Checklist for Prevalence Studies (JB checklist) to identify the methodological compliance of the selected articles.[22] This checklist was applied independently by five raters (JLAA, KVM, MOEC, JOLT, MKK) to be later verified by a sixth rater (CGC), who resolved the conflicts. The JB checklist was intended to assess the methodological quality of a study and determine whether there was bias in design, conduct, and analysis.

The results of this evaluation were used to inform compliance with items such as; Yes, No, Uncertain, or Not applicable (Table 1). Where studies did not meet most checklist items or the information needed to be more specific, they were excluded.

A total of 572 articles were identified in the electronic databases shown in Fig. 1. We excluded 533 articles because muscle strength and power data were not described, participants had muscular or genetic disorders, the focus of the study was different, or it was published in languages other than English or Spanish. Fifty-one articles were selected by title and abstract; 11 were eliminated due to being duplicated in the electronic databases consulted. Subsequently, the remaining 40 were reviewed entirely, resulting in the exclusion of 21 since the focus of the study was different and needed to describe the variables of interest; the other nine were excluded from the 19 remaining articles due to not describing evaluation methods or studying participants with a different approach. Subsequently, ten articles were selected. Therefore, we performed an intra-article review of the ten remaining articles and identified eight more articles; however, six were eliminated due to low quality (JB checklist) and the other one because of a lack of quantitative data. Finally, 11 articles were included in this work. (Fig. 1) The Kappa coefficient was calculated to assess the agreement between the raters, whose value was 0.82 (p ≤ 0.001) with a percentage agreement of 92%. Searching was replicated in February 2023, and we identified four articles by title, which were excluded due to the reasons discussed previously.

The 11 included articles were carried out between 2003 and 2023, with a total of 13,451 participants, of which seven were conducted in Europe;[23–28] two in America;[29, 30] one in Oceania;[31] and one in Asia,[32] Table 2. The sample size varied from 55 to 3206, with children and adolescents from 6 to 18 years of age. Only in two studies did the female sex predominate; [29, 32] however, most children and adolescents with obesity or overweight were male. (Table 2)

3.1. Muscle strength

The handgrip strength was higher in children and adolescents with overweight or obesity than in normal weight, especially in males.[24, 29, 32] Contrary, when upper limb strength was assessed in patients with overweight or obesity through a load of their weight (Bent arm hang test), the results were significantly lower compared to normal-weight patients, predominantly male. [23, 25] Similarly, in five articles, upper limb strength was assessed through pull-ups[29, 31]and push-up tests,[23, 30, 31] finding lower performance in the group with obesity.

Furthermore, the maximal strength of the knee extensor muscles was also higher in males with obesity participants than in normal weight.[29] In this regard, Deforche B. et al., 2003, Tokmakidis S. et al., 2006; Karppanen A K. et al., 2012; and Castro-Piñero J. et al., 2009 found a lower number of sit-ups in the obesity group compared to those of normal weight or non-obese group, as viewed in Table 3.[23–25, 28] In addition, one study [31] evaluated lower limb strength through the rising from a chair test, finding that participants with obesity were slower to get up from the chair than their counterparts. Moreover, Nunez-Gaunaurd N. et al., 2013, used timed tests for going up and down stairs, the Timed-Sit-to-Stand test and the Timed Up and Down Stairs test group with obesity as an indicator for lower limb strength, finding lower results in children with obesity compared to the group of participants with normal weight (OB: 1.8 ± 0.52; NW: 2.02 ± 0.52). [30] Lastly, Lazzer S. et al., 2009 reported that the peak force of the lower limbs measured through the Explosive Ergometer was higher in participants with obesity compared with their counterparts non-obese showing a significant difference between male and female participants (boys: OB 975.8 ± 20.6; non-OB 867.4 ± 21.3; girls: OB 927.8 ± 21.8; non-OB 689.5 ± 25.1) [27, 33] Table 3.

Some studies evaluated abdominal muscle strength, finding that the strength measured through plank and abdominal exercises was lower in the participants with obesity compared to those with normal weight and even those with overweight in both sexes, predominantly female.[23, 29]

3.2 Muscle power

Muscle power of the upper limbs was consistently higher in participants in the group with obesity [23, 26, 27, 31], especially in male participants. Only one study reported an increase in older age participants.[26]

On the other hand, we found reduced muscle power in the lower limbs in the group with obesity compared to children and adolescents with normal weight, higher in male participants compared to females (Table 4). [23–28, 31, 32] Only one study demonstrated greater muscle power in the lower limbs of the group of participants with obesity compared to overweight and normal weight with a predominance of males.[33]

3.3 Assessment tests or instruments

3.3.1 Muscle strength tests and Instruments

The most widely used measurement instrument for the evaluation of upper limb muscle strength was the hand dynamometer [24, 26, 29, 32] of different types (digital and mechanical), followed by indirect tests such as plank, pull-ups, or push-ups [29–31], and Bent arm hang as part of the EURO FIT battery[24, 25] or alone.[23] Abdominal muscle strength was assessed through abdominal curls[30] and sit-ups.[23–25, 28] For the evaluation of the strength of the lower limb muscles, the test used was the Explosive-Ergometer, (EXER, University of Udine, Udine, Italy), which assessed absolute peak strength of both limbs[26] and indirect tests such as rising from a chair test[31] the knee extension test[29] and Timed Sit-to-Stand test, and the Timed Up and Down Stair test (Table 3).[30]

3.3.2 Muscle power test and Instruments

The most used test to evaluate upper limb muscle power were the basketball throw, throwback ball, and forward throw tests.[23, 26, 27, 31] On the other hand, lower limb muscle power was primarily evaluated by jump tests, such as vertical jump, squat jump, standing broad jump, and long jump.[23, 25–28, 31] One study used a direct instrument, the Explosive Ergometer (EXER, University of Udine, Udine, Italy), to measure the absolute peak force of the lower extremities, an indicator of lower limb power. (Table 4) [33]

3.3.3. Quality of the evidence

The reporting methodological quality of the studies included showed a high risk of bias due to poor description of the measures taken to address the sample adequately, how the sample size was calculated, the strategies for performing the sampling, and whether the measurements were made through standardised and reliable instruments in all participants. (Table 1)

Among the most relevant findings of our review, we found that the strength of the upper limbs measured through hand grip dynamometry with mechanical or digital tools was higher in children and adolescents with overweight and obesity compared to those of normal weight. Nevertheless, other tests, such as push-ups and bent arm hang in their original and modified versions, reported reduced upper limb strength in these groups. In addition, we found that muscle power measured through tests performed through jumps in its different modalities was consistently decreased in participants with obesity and overweight compared to those with normal weight regardless of age and sex, showing us poor performance of the muscles of the lower limbs in children with obesity or overweight.

Tomlinson 2016 and Musálek, 2020, reported similar findings to ours in people living with obesity, who found greater absolute strength compared to people with normal weight, although less strength per unit of body mass, probably explained by the intrinsic factors with affectation in neuromuscular activation and functional performance, previously described.[14, 15, 34]

This review highlights poor muscular performance in overweight or obese participants when assessed through tests that involve repetitions (sit-ups, squats) or that support their body weight, such as planks, push-ups, pull-ups, and jumping jacks. However, we found a clear difference in strength assessed across tests such as grip strength and ball throwing, in which the tested participants did not carry their weight, performing better than normal-weight participants.

Another explanation to consider about the increase in strength in upper limbs in patients with overweight or obesity is the predominance of certain muscle fibres in upper limbs, for example, those of slow contraction (Type I) that are more resistant to fatigue, which explains in some way the elevated force found in the hand dynamometer test and ball throwing tests. On the contrary, in the muscles on the lower limb, which require greater strength, power, and speed for the execution of movements, the predominance of fast-twitch fibres (Type II) is noticeable, probably secondary to the structural changes due to obesity, the fatigue threshold and aerobic capacity reduced when body weight increases.[13]

Although it has been reported that muscle strength depends on these intrinsic muscle factors mentioned, other biological, psychological, social, and environmental factors favour physical activity and, in turn, strength and muscle power.[35]

In this sense, muscle strength is necessary to carry out daily life activities at each stage of life because muscle strength is relevant during childhood, a scenario in which they acquire new skills due to the nervous and musculoskeletal maturation process and the cardiorespiratory systems.[36]

Environmental, psychological, and social factors are conditions that we should not ignore that surround individuals with overweight or obesity since it has been reported that when these factors are appropriate, the probability increases that the person performs a daily physical activity, with the improvement of their physical capacities, as well as their power and muscular strength[35] and that it reduces the risk of developing sarcopenia related to inactivity.[37, 38]

An increase in physical activity of 60 to 200 minutes per week in prepubertal schoolchildren has been reported to be associated with increased muscular strength and endurance.[39] Muscular strength and endurance training positively affect all body systems by improving aerobic capacity and preventing disease development from an early age.[40]

Despite the valuable information provided by our review, we recognise its limitations due to the great diversity and the number of tests used to measure study participants, which were sometimes 'adapted' for use in children and adolescents, diminishing the validity of their results and those of this review. However, despite the above, our review evidenced a consistent decrease in strength and power in overweight and obese children and adolescents in all studies included that could interfere with the treatment plan of these patients.

There are great differences in absolute muscle power and strength between overweight children and adolescents with obesity and those with normal weight. Therefore, we recommended using validated tests in these age groups, preferably those that assess strength through the load of the patient's body weight, either of the upper or lower limbs, for greater objectivity in the assessment that facilitates the management of these children and adolescents.

Ethics approval and consent to participate:

Not applicable

Consent for publication:

Not applicable

Availability of data and materials:

All data used and/or analysed during this study are included in this published article.

Competing interests:

The authors declare that they have no competing interests

Funding.

This review did not receive any financial support.

Authors' contributions:

Conceiving protocol and coordinating the review: CGC, MKK; designing the protocol, searching strategies, and undertaking searches: CGC, JLAA, MEOC, JOLT, KVM screening search results, and retrieving papers: JLAA, KVM, MEOC, JOLT, CGC, MKK; appraising the quality of papers: CGC, MKK, JLAA, KVM, MEOC, JOLT.; extracting data from reports: JLAA, KVM, MEOC, JOLT, CGC; writing the review: CGC, MKK, JLAA. All authors read and approved the final manuscript.

Acknowledgements:

Not applicable

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Tables 1 to 4 are available in the Supplementary Files section.

No competing interests reported.

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Differences in the absolute muscle strength and power of children and adolescents with overweight or obesity. A systematic review

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Abstract

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Background

Material and methods

Results

Discussion

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Status:

Journal Publication

Version 1