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Exercise effects on arterial stiffness and heart health in children with excess weight: The SMART RCT



Childhood obesity and inactivity are associated with cardiovascular risk. Evidence is limited for exercise effects on arterial health in children.


One hundred and seventy-five inactive children with overweight or obesity (8–11 years, ≥85th percentile BMI, 61% female, 87% Black, 73% with obesity) were randomized to an 8-month daily after-school aerobic exercise program (40 min/day, n = 90) or a sedentary control condition (n = 85). Carotid-femoral pulse wave velocity (PWV, primary outcome, arterial stiffness), fitness, adiposity, blood pressure (BP), glucose, insulin resistance, lipids, and C-reactive protein were measured at baseline and posttest (8 months). Adiposity, fitness, and BP were measured again at follow-up, 8–12 months later. Intent-to-treat analyses were conducted using mixed models.


The study had 89% retention, with attendance of 59% in exercise and 64% in the control condition, and vigorous exercise participation (average heart rate 161 ± 7 beats/min). Compared with controls, the exercise group had twice the improvement in fitness (VȮ2 peak, 2.7 (95% CI 1.8, 3.6) vs. 1.3 (0.4, 2.3) mL/kg/min) and adiposity (−1.8 (−2.4, −1.1) vs. −0.8 (−1.5, −0.1)%), each p = 0.04, and a large improvement in HDL-cholesterol (0.13 (0.075, 0.186) vs. −0.028 (−0.083, 0.023) mmol/L, p < 0.0001). There was no group × time effect on other outcomes at 8 months, or on any outcomes at follow-up. The change in PWV at 8 months correlated with changes in insulin and insulin resistance (both r = 0.32), diastolic BP (r = 0.24), BMI (r = 0.22), and adiposity (r = 0.18).


Eight months of aerobic exercise training improved fitness, adiposity, and HDL-cholesterol levels, but did not reduce arterial stiffness in children with excess weight. PWV improved as a function of insulin resistance, BP, BMI, and adiposity. Weight loss may be required to improve arterial stiffness. Exercise benefits waned after discontinuing the program.

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The authors acknowledge Amanda Gipson for assistance with accelerometry, and Barbara Gower at the University of Alabama at Birmingham for insulin, glucose, and lipid assays. This work was supported by NIH grants R01 HL087923, P30 DK56336, and P30 DK079626, and a Diabetes & Obesity Discovery Institute grant and Medical Scholars Program stipends from the Medical College of Georgia. The study was approved by the MCG IRB (Human Assurance Committee; 02-08-037, 09-04-287).

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CLD conceived the study, drafted the manuscript and oversaw data collection and analysis. SEL assisted with drafting the manuscript. NKP assisted with analyses and drafting the manuscript. JLW assisted with design of the study and conducted intent-to-treat statistical analyses. HZ measured C-reactive protein and reviewed the manuscript. YD and GK assisted with design of the study, PWV data collection, and reviewed the manuscript. JB assisted with quality control of the PWV data. RAH oversaw fitness testing and assisted with drafting the manuscript. JL conducted the interventions and data collection, quality control of data, edited the video, and assisted with drafting the manuscript. CFW assisted with statistical analyses, quality control, and drafting the manuscript. AA assisted with data analyses. MDS assisted with accelerometry analyses. RB consulted on design, provided medical oversight for the study, and assisted with drafting the manuscript. All authors reviewed the manuscript prior to submission.

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Correspondence to Catherine L. Davis.

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Davis, C.L., Litwin, S.E., Pollock, N.K. et al. Exercise effects on arterial stiffness and heart health in children with excess weight: The SMART RCT. Int J Obes 44, 1152–1163 (2020).

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