RESUMEN
Lower HMW (high molecular weight) adiponectin levels are associated with obesity, insulin resistance, and metabolic syndrome in children and adolescents. However, data on HMW levels in pediatric population with hypertension are lacking. This study aimed to examine the association and predictive capacity of HMW levels, HMW/HOMA-IR, and HMW/APN ratio with hypertension in obese children and adolescents. The 299 pediatric subjects were grouped in obese hypertensive (OH), obese normotensive (ON), and normal weight normotensive (NN). Plasma concentrations of HMW were investigated by ELISA. ANOVA was used to compare study groups, and a binary logistic regression analysis was used to verify if HMW, HMW/HOMA-IR, HMW/APN, APN, APN/HOMA-IR, and HOMA-IR are associated to hypertension regardless obesity in children and adolescents. To compare the strength and performance of each biomarker to classify individuals with and without hypertension, the receiver-operating characteristic (ROC) curve, area under the curve (AUC), and Youden index (J) were evaluated. Both HMW plasma levels and the HMW/HOMA-IR ratio were significantly lower in the OH group when compared to the ON group (HMW: 2.00 ± 1.33 µg/mL vs 2.48 ± 1.48 µg/mL; HMW/HOMA-IR ratio: 0.87 ± 0.95 vs 1.27 ± 1.2; P < 0.05) and NN weight groups (HMW: 2.00 ± 1.33 µg/mL vs 4.02 ± 1.99 µg/mL; HMW/HOMA-IR ratio: 0.87 ± 0.95 vs 2.62 ± 1.86; P < 0.05). Hypertension was associated with lowest HMW (OR = 4.50; 95% CI = 1.41-15.84) and HMW/HOMA-IR (OR = 12.13; 95% CI = 2.51-92.93) regardless of obesity. However, HOMA-IR or the HMW/APN was not significant (P > 0.05). In the ROC curve analyses, the HMW and HMW/HOM-IR were more sensitive to detect hypertension in children and adolescents with obesity. Conclusion: Low levels of HMW oligomer and HMW/HOM-IR are associated with hypertension in childhood obesity. Thus, these biomarkers could be clinically useful in identifying hypertension in childhood obesity. What is Known: ⢠HMW has previously been reported as the most biologically active isoform of adiponectin, and lower HMW concentrations are associated with obesity, insulin resistance, and metabolic syndrome in children and adolescents. ⢠HMW/HOMA-IR ratio is a sensitive predictor for metabolic syndrome in adults. What is New: ⢠HMW levels are associated with hypertension in children and adolescents, independently of presence of obesity. ⢠HMW was more sensitive to detect hypertension in children and adolescents with obesity when compared to HMW/HOMA-IR, HMW/APN, APN, APN/HOMA-IR, or HOMA-IR.
Asunto(s)
Hipertensión , Resistencia a la Insulina , Síndrome Metabólico , Obesidad Infantil , Adulto , Adolescente , Niño , Humanos , Obesidad Infantil/complicaciones , Síndrome Metabólico/complicaciones , Síndrome Metabólico/diagnóstico , Adiponectina , Peso Molecular , Biomarcadores , Hipertensión/complicaciones , Hipertensión/diagnósticoRESUMEN
The endogenous ability to decrease pain perception during life-threatening situations is crucial to the prevention of recuperative behaviors and to leave the subject free to engage in appropriated defensive responses. We have previously shown that acute pain activates the ascending nociceptive control-an endogenous analgesia circuit dependent on opioid mechanisms within nucleus accumbens-to facilitate the tonic immobility response, an innate defensive behavior. Now we asked whether chronic pain and pain chronification impairs either the tonic immobility response or the ability of acute pain to facilitate it by activating the ascending nociceptive control. We found a significant decrease in the duration of the tonic immobility response in rats during the induction and maintenance phases of the persistent mechanical hyperalgesia. This finding suggests that chronic pain and its development impair defensive responses. However, during the induction and maintenance phases of persistent hyperalgesia, the ascending nociceptive control activation, by a forepaw capsaicin injection, increased the tonic immobility response, an effect prevented by the blockade of µ-opioid receptors within nucleus accumbens. This finding suggests that pain chronification and chronic pain do not prevent the ability of acute pain to facilitate the defensive behavior of tonic immobility by activating the ascending nociceptive control. Therefore, although chronic pain states decrease the ability to engage in a defensive behavior, they may not prevent the expression of defensive behaviors during life-threatening situations accompanied by acute pain. The biological purpose of such a mechanism may be to increase the chances of survival of a wounded subject exposed to acute pain in a novel life-threatening situation. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Asunto(s)
Dolor Agudo/fisiopatología , Dolor Crónico/fisiopatología , Reacción Cataléptica de Congelación/fisiología , Núcleo Accumbens/fisiopatología , Percepción del Dolor/fisiología , Dolor Agudo/psicología , Animales , Capsaicina , Dolor Crónico/psicología , Hidroxiácidos , Hiperalgesia/fisiopatología , Hiperalgesia/psicología , Masculino , Vías Nerviosas/efectos de los fármacos , Vías Nerviosas/fisiopatología , Dolor Nociceptivo/fisiopatología , Dolor Nociceptivo/psicología , Núcleo Accumbens/efectos de los fármacos , Ácidos Oléicos , Distribución Aleatoria , Ratas Wistar , Receptores Opioides mu/antagonistas & inhibidores , Receptores Opioides mu/metabolismoRESUMEN
Objective: To investigate the association between serum uric acid levels and insulin resistance in children and adolescents with obesity. Methods: Cross-sectional study with 245 children and adolescents (134 obese and 111 controls), aged 8-18 years. The anthropometric variables (weight, height and waist circumference), blood pressure and biochemical parameters were collected. The clinical characteristics of the groups were analyzed by t-test or chi-square test. To evaluate the association between uric acid levels and insulin resistance the Pearson's test and logistic regression were applied. Results: The prevalence of insulin resistance was 26.9%. The anthropometric variables, systolic and diastolic blood pressure and biochemical variables were significantly higher in the obese group (p<0.001), except for the high-density-lipoprotein cholesterol. There was a positive and significant correlation between anthropometric variables and uric acid with HOMA-IR in the obese and in the control groups, which was higher in the obese group and in the total sample. The logistic regression model that included age, gender and obesity, showed an odds ratio of uric acid as a variable associated with insulin resistance of 1.91 (95%CI 1.40-2.62; p<−0.001). Conclusions: The increase in serum uric acid showed a positive statistical correlation with insulin resistance and it is associated with and increased risk of insulin resistance in obese children and adolescents.
Objetivo: Investigar a associação entre os níveis séricos de ácido úrico e a resistência insulínica em crianças e adolescentes com obesidade. Métodos: Estudo transversal, com 245 crianças e adolescentes (134 obesos e 111 controles), entre oito e 18 anos. Foram coletadas variáveis antropométricas (peso, estatura e circunferência abdominal), pressão arterial e parâmetros bioquímicos. As características clínicas dos grupos foram analisadas pelo teste t ou pelo qui-quadrado. Para avaliar a associação entre os níveis de ácido úrico e a resistência insulínica usaram-se o teste de Pearson e regressão logística. A resistência insulínica foi a variável dependente no modelo de regressão. Resultados: A prevalência de resistência insulínica foi de 26,9%. As variáveis antropométricas, a pressão arterial sistólica e diastólica e as variáveis bioquímicas foram maiores no grupo obeso (p<0,001), exceto o colesterol de alta densidade. Foi observada correlação positiva e significativa entre as variáveis antropométricas e o ácido úrico com o HOMA-IR no grupo obeso e no controle. Essa foi maior no grupo obeso e na amostra total. No modelo de regressão logística que incluiu idade, sexo e obesidade, a odds ratio do ácido úrico como fator associado à resistência insulínica foi de 1,91 (IC95% 1,40-2,62; p<0,001). Conclusões: Observa-se que o aumento no nível sérico de ácido úrico apresenta correlação estatística positiva com a resistência insulínica e está associado à elevação no risco em crianças e adolescentes obesos.
Asunto(s)
Humanos , Masculino , Femenino , Niño , Adolescente , Obesidad Infantil , Resistencia a la Insulina , Ácido ÚricoRESUMEN
OBJECTIVE: To investigate the association between serum uric acid levels and insulin resistance in children and adolescents with obesity. METHODS: Cross-sectional study with 245 children and adolescents (134 obese and 111 controls), aged 8 to 18 years. The anthropometric variables (weight, height and waist circumference), blood pressure and biochemical parameters were collected. The clinical characteristics of the groups were analyzed by t-test or chi-square test. To evaluate the association between uric acid levels and insulin resistance the Pearson's test and logistic regression were applied. RESULTS: The prevalence of insulin resistance was 26.9%. The anthropometric variables, systolic and diastolic blood pressure and biochemical variables were significantly higher in the obese group (p<0.001), except for the high-density-lipoprotein cholesterol. There was a positive and significant correlation between anthropometric variables and uric acid with HOMA-IR in the obese and in the control groups, which was higher in the obese group and in the total sample. The logistic regression model that included age, gender and obesity, showed an odds ratio of uric acid as a variable associated with insulin resistance of 1.91 (95%CI 1.40 to 2.62; p<-0.001). CONCLUSIONS: The increase in serum uric acid showed a positive statistical correlation with insulin resistance and it is associated with and increased risk of insulin resistance in obese children and adolescents.
Asunto(s)
Resistencia a la Insulina/fisiología , Obesidad Infantil/sangre , Ácido Úrico/sangre , Adolescente , Presión Sanguínea , Estatura , Índice de Masa Corporal , Peso Corporal , Niño , Estudios Transversales , Humanos , Obesidad Infantil/fisiopatología , Factores de RiesgoRESUMEN
OBJECTIVE: To compare the circulating levels of MMP-2 and TIMP-2 and the MMP-2/TIMP-2 ratio in control, obese, and obese hypertensive children and adolescents and to assess whether hypoadiponectinemia is associated with MMP-2 and TIMP-2 levels and MMP-2/TIMP-2 ratios. METHODS: Studies were carried out with 53 control, 73 obese, and 29 obese hypertensive children and adolescents in this cross-sectional study. Adiponectin and TIMP-2 concentrations were measured by ELISA. MMP-2 concentrations were measured by gelatin zymography. Multiple linear regression analysis was carried out to assess the effects of adiponectin on MMP-2 and TIMP-2 levels and MMP-2/TIMP-2 ratios. RESULTS: The obese hypertensive group had the lowest adiponectin levels among groups (P < 0.05) while obese subjects had lower adiponectin levels than control subjects (P < 0.05). Obese hypertensive subjects also had higher circulating MMP-2 concentrations than obese subjects (P < 0.05) and had the highest MMP-2/TIMP-2 ratios among groups (P < 0.05). Moreover, obese/hypertensive subjects had the lowest TIMP-2 levels among groups (P < 0.05). A multiple linear regression analysis showed that MMP-2 levels and MMP-2/TIMP-2 ratios are negatively associated with adiponectin levels (P = 0.034 and P = 0.011, respectively) while TIMP-2 levels is positively associated with adiponectin levels (P = 0.013). CONCLUSIONS: Increased activity of MMP-2 (MMP-2/TIMP-2 ratio) and reduced TIMP-2 levels may play an important role in clinical hypertension of childhood obesity. Additionally, hypoadiponectinemia may contribute to increased activity of MMP-2 in obese/hypertensive children and adolescents.
Asunto(s)
Adiponectina/deficiencia , Hipertensión/metabolismo , Metaloproteinasa 2 de la Matriz/metabolismo , Errores Innatos del Metabolismo/metabolismo , Obesidad Infantil/metabolismo , Adiponectina/metabolismo , Adolescente , Estudios de Casos y Controles , Niño , Estudios Transversales , Ensayo de Inmunoadsorción Enzimática , Femenino , Humanos , Hipertensión/complicaciones , Masculino , Metaloproteinasa 2 de la Matriz/sangre , Errores Innatos del Metabolismo/complicaciones , Obesidad Infantil/complicaciones , Análisis de Regresión , Inhibidor Tisular de Metaloproteinasa-2/sangreRESUMEN
OBJECTIVE: To test the hypothesis that obese normotensive children and adolescents present impaired cardiac autonomic control compared to non-obese normotensive ones. METHODS: For this cross-sectional study, 66 children and adolescents were divided into the following groups: Obese (n=31, 12±3 years old) and Non-Obese (n=35, 13±3 years old). Obesity was defined as body mass index greater than the 95th percentile for age and gender. Blood pressure was measured by oscillometric method after 15 minutes of rest in supine position. The heart rate was continuously registered during ten minutes in the supine position with spontaneous breathing. The cardiac autonomic control was assessed by heart rate variability, which was calculated from the five-minute minor variance of the signal. The derivations were the index that indicates the proportion of the number of times in which normal adjacent R-R intervals present differences >50 miliseconds (pNN50), for the time domain, and, for the spectral analysis, low (LF) and high frequency (HF) bands, besides the low and high frequencies ratio (LF/HF). The results were expressed as mean±standard deviation and compared by Student's t-test or Mann-Whitney's U-test. RESULTS: Systolic blood pressure (116±14 versus 114±13mmHg, p=0.693) and diastolic blood pressure (59±8 versus 60±11mmHg, p=0.458) were similar between the Obese and Non-Obese groups. The pNN50 index (29±21 versus 43±23, p=0.015) and HF band (54±20 versus 64±14 normalized units - n.u., p=0.023) were lower in the Obese Group. The LF band (46±20 versus 36±14 n.u., p=0.023) and LF/HF ratio (1.3±1.6 versus 0.7±0.4, p=0.044) were higher in Obese Group. CONCLUSIONS: Obese normotensive children and adolescents present impairment of cardiac autonomic control.
Asunto(s)
Sistema Nervioso Autónomo/fisiopatología , Corazón/fisiopatología , Obesidad Infantil/fisiopatología , Adolescente , Presión Sanguínea , Niño , Estudios Transversales , Femenino , Humanos , Masculino , Valores de ReferenciaRESUMEN
To test the hypothesis that obese normotensive children and adolescents present impaired cardiac autonomic control compared to non-obese normotensive ones. METHODS: For this cross-sectional study, 66 children and adolescents were divided into the following groups: Obese (n=31, 12±3 years old) and Non-Obese (n=35, 13±3 years old). Obesity was defined as body mass index greater than the 95th percentile for age and gender. Blood pressure was measured by oscillometric method after 15 minutes of rest in supine position. The heart rate was continuously registered during ten minutes in the supine position with spontaneous breathing. The cardiac autonomic control was assessed by heart rate variability, which was calculated from the five-minute minor variance of the signal. The derivations were the index that indicates the proportion of the number of times in which normal adjacent R-R intervals present differences >50 miliseconds (pNN50), for the time domain, and, for the spectral analysis, low (LF) and high frequency (HF) bands, besides the low and high frequencies ratio (LF/HF). The results were expressed as mean±standard deviation and compared by Student's t-test or Mann-Whitney's U-test. RESULTS: Systolic blood pressure (116±14 versus 114±13mmHg, p=0.693) and diastolic blood pressure (59±8 versus 60±11mmHg, p=0.458) were similar between the Obese and Non-Obese groups. The pNN50 index (29±21 versus 43±23, p=0.015) and HF band (54±20 versus 64±14 normalized units - n.u., p=0.023) were lower in the Obese Group. The LF band (46±20 versus 36±14 n.u., p=0.023) and LF/HF ratio (1.3±1.6 versus 0.7±0.4, p=0.044) were higher in Obese Group. CONCLUSIONS: Obese normotensive children and adolescents present impairment of cardiac autonomic control...
Probar la hipótesis de que niños y adolescentes obesos normotensos presentan disfunción autonómica cardiaca cuando comparados a individuos no obesos también normotensos. MÉTODOS: Estudio transversal con 66 niños y adolescentes, divididos en los grupos Obeso (n=31, 12±3 años) y No obesos (n=35, 13±3 años). Se definió la obesidad por el índice de masa corporal superior al percentil 95, considerándose edad y sexo. Se verificó la presión arterial clínica por oscilometría después de 15 minutos de reposo en posición supina. Se registró la frecuencia cardiaca durante 10 minutos en la posición supina, con respiración espontánea. Se evaluó el control autonómico cardiaco por la variabilidad de la frecuencia cardiaca, calculada a partir de los cinco minutos de menor variancia de la señal. Fueron derivados el índice que indica la proporción del número de veces en que los intervalos R-R normales sucesivos presentan diferencia de duración superior a 50 milisegundos (pNN50) para el dominio del tiempo y, para el análisis espectral, las bandas de baja (LF) y alta (HF) frecuencias, además de la razón entre las bandas espectrales de baja y alta frecuencia (LF/HF). Los resultados se presentaron como promedio±desviación estándar, siendo comparados por la prueba t de Student o por la prueba U de Mann-Whitney. RESULTADOS: Los niveles de presión arterial sistólica (116±14 versus 114±13mmHg, p=0,693) y diastólica (59±8 versus 60±11mmHg, p=0,458) fueron semejantes entre los grupos Obeso y No obeso, respectivamente. El índice pNN50 (29±21 versus 43±23; p=0,015) y la banda HF (54±20 versus 64±14 unidades normalizadas - u.n.; p=0,023) fueron menores en el Grupo Obeso...
Testar a hipótese de que crianças e adolescentes obesos normotensos apresentam disfunção autonômica cardíaca quando comparados a indivíduos não obesos também normotensos. MÉTODOS: Estudo transversal com 66 crianças e adolescentes, divididos nos grupos Obeso (n=31, 12±3 anos) e Não Obeso (n=35, 13±3 anos). Definiu-se a obesidade pelo índice de massa corpórea maior que o percentil 95, considerando-se idade e sexo. Aferiu-se a pressão arterial clínica por oscilometria após 15 minutos de repouso em posição supina. Registrou-se a frequência cardíaca durante dez minutos na posição supina, com respiração espontânea. Avaliou-se o controle autonômico cardíaco pela variabilidade da frequência cardíaca, calculada a partir dos cinco minutos de menor variância do sinal. Foram derivados o índice que indica a proporção do número de vezes em que os intervalos R-R normais sucessivos apresentam diferença de duração superior a 50 milisegundos (pNN50) para o domínio do tempo e, para a análise espectral, as bandas de baixa (LF) e alta (HF) frequências, além da razão entre as bandas espectrais de baixa e alta frequência (LF/HF). Os resultados apresentam-se como média±desvio padrão, sendo comparados pelo teste t de Student ou pelo teste U de Mann-Whitney. RESULTADOS: Os níveis de pressão arterial sistólica (116±14 versus 114±13mmHg, p=0,693) e diastólica (59±8 versus 60±11mmHg, p=0,458) foram semelhantes entre os grupos Obeso...
Asunto(s)
Humanos , Masculino , Femenino , Niño , Adolescente , Enfermedades del Sistema Nervioso Autónomo/complicaciones , Frecuencia Cardíaca , Obesidad/complicaciones , Presión ArterialRESUMEN
We investigated whether genetic polymorphisms in the endothelial nitric oxide (eNOS) gene (T(786)C in the promoter region, Glu298Asp in exon 7, and 4b/4a in intron 4) or eNOS haplotypes are associated with metabolic syndrome (MetS) in obese children and adolescents. We studied 242 subjects: 108 healthy (controls), 64 normotensive obese, and 70 obese children and adolescents with MetS. Genotypes were determined by Taqman(®) allele discrimination assay and real-time polymerase chain reaction (PCR), and PCR followed by fragment separation by electrophoresis. We compared the distribution of eNOS genotypes, alleles, and haplotypes in the three groups of subjects. The CC genotype for the T(786)C polymorphism was more common in the MetS group than in the control group (OR = 3.27; CI 1.81-9.07; P < 0.05). However, we found no significant differences in the distribution of eNOS haplotypes (P > 0.00625; P for significance after correction for multiple comparisons). Our findings suggest that while eNOS haplotypes are not relevant, the CC genotype for the T(786)C polymorphism is associated with MetS in obese children and adolescents. Further studies examining interactions of eNOS haplotypes with environmental factors and other genetic markers are warranted.
Asunto(s)
Síndrome Metabólico/genética , Repeticiones de Minisatélite , Óxido Nítrico Sintasa de Tipo III/genética , Polimorfismo de Nucleótido Simple , Adolescente , Niño , Femenino , Frecuencia de los Genes , Estudios de Asociación Genética , Predisposición Genética a la Enfermedad , Haplotipos , Humanos , Masculino , Síndrome Metabólico/enzimología , Obesidad/enzimología , Obesidad/genética , Regiones Promotoras Genéticas , Análisis de Secuencia de ADNRESUMEN
INTRODUÇÃO: Estudos recentes em imagem corporal têm buscado desenvolver conjuntos de silhuetas com as características de grupos específicos. Para o fisiculturismo, ainda não foram desenvolvidos conjuntos de silhuetas que representem mais detalhadamente o conjunto das estruturas corporais. Para esse esporte, os detalhes são essenciais. OBJETIVO: Propor um conjunto de silhuetas específico para fisiculturista composto por fotografias (fotossilhuetas). Método: O estudo foi estruturado em três fases: 1) fotografia dos fisiculturistas, seleção e organização das fotos pelos pesquisadores; 2) organização das fotos por professores e treinadores de fisiculturistas; e 3) aplicação do conjunto de fotossilhuetas proposto. RESULTADOS: Fase 1 - os valores de IMC se distribuíram em ordem crescente (IMC de 24,1 até 35,6kg/m²); Fase 2 - participaram seis professores de educação física e seis treinadores de fisiculturismo e todos ordenaram as fotossilhuetas na mesma ordem crescente que os pesquisadores; e Fase 3 - participaram 20 fisiculturistas, apenas um não apontou o conjunto proposto como preferido para avaliação perceptiva da imagem corporal. Entre as silhuetas atribuídas pelos três pesquisadores, observou-se correlação intraclasse de 0,92. Comparando a média das silhuetas atribuídas pelos pesquisadores (3,8 ± 1,0) e a média das silhuetas atribuídas pelos atletas (3,9 ± 1,0), não se encontrou diferença significativa e correlação de 0,75 (p < 0,05). CONCLUSÃO: Conclui-se que o conjunto de fotossilhuetas é válido para o estudo da dimensão perceptiva da imagem corporal de fisiculturistas no que diz respeito à identificação da silhueta atual.
INTRODUCTION: Recent studies on body image have proposed sets of silhouettes with the characteristics of specific groups. Sets of silhouettes specifically developed to depict in detail the body structures of bodybuilders have not been developed yet. Details are essential to this sport. OBJECTIVE: to propose a specific set of silhouettes to bodybuilders, composed of photos (photo silhouettes). Method: The study was structured in three phases: 1) photos of bodybuilders, selection and organization of the photos by the researchers; 2) organization of the photos by teachers and bodybuilding coaches; 3) application of the proposed set of photo silhouettes. RESULTS: Phase 1 - the BMI values were distributed in increasing order (BMI from 24.1 to 35.6 kg/m2); Phase 2 - six physical education teachers and six bodybuilding coaches participated and all of them organized the photo silhouettes in the same increasing order proposed by the researchers. Phase 3 - 20 bodybuilders participated; only one of them did not point the set of photo silhouettes proposed as the preferred for the perceptive assessment of body image. Considering the three silhouettes attributed by the researchers, intraclass correlation of 0.92 was observed. Comparing the silhouette mean attributed by the researchers (3.8 +/- 1.0) and the mean attributed by athletes (3.9 +/- 1.0) significant difference and a correlation of 0.75 (p<0.05) have not been found. CONCLUSION: It was concluded that the set of photo silhouettes is valid for the study of perceptive dimension of the body image of bodybuilders concerning the identification of the current silhouette.
Asunto(s)
Humanos , Antropometría , Imagen Corporal , Índice de Masa Corporal , DeportesRESUMEN
A obesidade é uma doença multifatorial, caracterizada pelo acúmulo excessivo de tecido adiposo corporal. Alterações fisiopatológicas associadas e/ou decorrentes ao aumento do tecido adiposo corporal, como aumento nas propriedades inflamatórias, disfunção endotelial e alterações do sistema nervoso autossômico promovem a instalação adicional de fatores de risco cardiovascular. De fato, esse cenário representa impacto negativo sobre a saúde cardiovascular e, consequentemente, na expectativa de vida. Por outro lado, a prática regular de exercício físico tem sido prescrita como medida não farmacológica para prevenção e tratamento da obesidade. Assim, o objetivo desse artigo foi realizar uma revião de literatura sobre os defeitos do treinamento físico nas propriedades inflamatórias, função endotelial e controle autossômico de pessoas obesas. O treinamento físico não só reduz o peso corporal, como também diminui as concentrações plasmáticas de propriedades pré-inflamatórias, aumenta os níveis de adiponectina, mehora a função endotelial, diminui a hiperatividade simpática e aumenta o tônus parassimpáticos. Porém, para que todos esses efeitos sejam obtidos, o treinamento físico deve ser realizado de forma adequada e com orientação e prescrição de especialistas.