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To present clinical experience with the short-term effect of a multi-disciplinary intervention on body weight, BMI and fitness in obese Israeli children and adolescents. In addition, we determined the effect of gender, maturation, degree of obesity, and parental overweight on body weight and BMI responses to the multi-disciplinary program.

Children must be obese and aged 6-16 years

No organic cause for his/her obesity and none received any medication which would interfere with growth or weight control (e.g., corticosteroids, thyroid hormones).

The frequency of visits to the dietitian during the program was once a month. The participants in these meetings differed according to the age of the patients. 

• In children aged 6-8 yrs, only the parents were invited for the first two meetings and the children joined the meetings thereafter. 
• Children older than 8 years were invited with both parents to all meetings. 
• Pubertal subjects were invited to the first meeting with both parents, and then, alternately, the adolescent and his/her parents met the dietitians separately. 

Dietary Intervention

Each family was instructed to come to the first meeting with a 24 hour diet recall.  The first appointment, 45-60 minutes long, was dedicated to acquaintance, learning about the reasons for childhood obesity, receiving information about food choices, dietary and cooking habits, understanding the motivation for weight loss, as well as trying to enroll the whole family in the “battle” against overweight.  The following appointments, 30-45 minutes each, were devoted mainly to nutritional education.  In addition, children received dietary information in the form of worksheets on important nutritional issues such as the food pyramid, fruits and vegetables, calcium intake and needs, special dietary consideration during holidays, and how to deal with food during a big celebration, vacations, restaurants, etc.

Subjects were given a balanced hypocaloric diet (1200-2000 kcal depending on the age and weight of the child). The calorie deficit was either 30% less than reported intake or 15% less than estimated daily required intake.

Physical Activity/Inactivity Intervention

All subjects participated in a twice-weekly training program.  Training was directed by professional youth coaches in a training center of a regional school located near the hospital.  The intervention was designed to mimic the type and intensity of exercise that elementary and high school children normally perform.  These activities were varied in duration and intensity throughout the program and were designed primarily as games to encourage enthusiasm and participation of the subjects.  Endurance type activities were accounted for most of the time spent in training with attention to coordination and flexibility skills.  The physicians who were worked in the program participated regularly in the training sessions in order to encourage the children and provide an example.

In order to encourage personal responsibility, subjects were instructed to add an extra 30-45 minutes of walking/other sport activity at least once a week.  These activities were reported to the coach at the end of the last training session each week.  Subjects were encouraged throughout the program by the physicians, nutritionist and coaches to reduce inactivity (e.g., television viewing, video games, use stairs instead of lifts, play outside instead of inside, etc.).

Standard, calibrated scales and standiometers were used to determine height, weight, and BMI percentile for each child using the recently published standards from the Centers for Disease Control, National Center for Health Statistics. Subjects were divided into mild-moderate obesity (BMI 85%-95%), and moderate-severe obesity (BMI greater than 95%).  BMI was calculated weekly throughout the 3 months or 6 months program.  Body weight and height were measured using the same scale and standiometer, at the same place and day of the week, and during the same time of the day.

177 obese children (age 6-16 years) and a group of 25-age-and maturity-matched obese children who did not participate in the structured program served as controls.

There were no significant differences in age, gender, pubertal status, television viewing, BMI, degree of obesity and parental overweight prior to the combined dietary and exercise intervention between the subjects who participated in the 3 month intervention, those who continued for the 6 month intervention, and controls. Endurance time was significantly greater in subjects of the 3 month intervention compared to those of the 6 month intervention, but both groups did not differ significantly form the controls.  BMI correlated significantly with hours of television viewing and computer playing.

During the intervention period, 27 subjects withdrew from the program due to transportation difficulties.  Therefore, 177 subjects were left.

Three Month Outcomes

Weight and BMI

Following the 3 months intervention, 65% of the participants (117 subjects) lost weight and in 74% (133 subjects), BMI was reduced.  The decrease in body weight (from 55.8 ±1.2 kg to 54.9 kg) and BMI (from 26.1 ± 0.3 kg/m² to 25.4 ± 0.3 kg/m²) was statistically significant.  Changes in body weight and BMI following the 3 months program were not significantly affected by gender, pubertal status, degree of obesity, or by parental overweight. 

In contrast, there was a significant increase in body weight (from 54.2 ± 5.3 kg to 55.8 ±5.2 kg) and BMI (from 25.2 ± 1.4 kg/m² to 25.6 ± 1.4 kg/m²) in the control subjects.  None of the control subjects lost weight and BMI was reduced only in two subjects.

Exercise and Reduction in Inactivity

Of the intervention participants, 49% reported that they performed a single exercise bout and 23% performed two exercise bouts in addition to the intervention.  Among the control subjects, only two subjects increased exercise (once and twice a week). 

Screen time (television and computer) was significantly reduced following the intervention, but did not change in the control subjects (from 31.0 ± 0.9 /week to 27.7 ± 1.2 h/week and from 30.5 ± 1.4 h/week to 30.3 ± 1.6 h/week in the intervention and control subjects, respectively; P< 0.01).

Fitness

Endurance time increased significantly in both groups, but the increase in the intervention participants was significantly greater (from 629 ± 24 seconds to 793 ± 24 seconds and from 560 ± 55 seconds to 586 +/- 42 seconds in the intervention and control subjects, respectively; P< 0.0005).  Changes in endurance time correlated negatively with changes in body weight (r = -0.31; P< 0.005), and BMI (r= -0.24; P< 0.01).  Changes in endurance time following the 3 month program were not significantly effected by gender, pubertal status, degree of obesity, or by parental overweight.

Nutrition

The nutritional intervention differed according to the age of the participants.  BMI changes were not significantly different in subjects younger than 8 years, 8 years old to puberty, and adolescents (-0.79 ± 0.24 kg/m², -0.72 ± 0.16 kg/m² and –0.85 ± 0.16 kg/m², respectively).

Six Month Outcomes

Weight and BMI

A total of 65 subjects continued the intervention for 6 months.  The decrease in body weight and BMI in these subjects was significantly greater compared to subjects who discontinued the program after 3 months (body weight: -0.58 ± 0.18 kg vs. –1.25 ± 0.36 kg in 3 months and 6 months participants respectively; P<0.05; BMI: -0.53 ± 0.09 kg/m² vs. –0.95 ± 0.16 kg/m² in 3 months and 6 months participants respectively; P<0.01).

During the 6 months, 37% of the participants (24 subjects) lost weight and in 69% (45 subjects), BMI was reduced.  There was a significant decrease in body weight (-0.50 ± 0.55 kg) and BMI (-1.07 ± 0.23 kg/m²) during the 6 months intervention.  However, this was mainly due to decreases in body weight and BMI in the first 3 months (body weight change:  0-3 months; -1.25 ± 0.44 kg, 3-6 months: 0.75 ± 0.27 kg; BMI change: 0-3 months: -0.95 ± 0.16 kg/m² , 3-6 months: -0.13 ± 0.13 kg/m²).  In contrast, only one of the control subjects lose weight and BMI was reduced only in two, and both body weight (3.23 ± 0.47 kg) and BMI (0.72 ± 0.17 kg/m²) increased significantly (P<0.005).

Changes in body weight and BMI following the 6 months program were not significantly affected by gender, pubertal status, and the degree of obesity of the participants.  During the second 3 months of the program (3 months – 6 months), subjects without parental overweight had significantly favourable BMI changes compared to subjects who had bad both obese parents.

Endurance

Endurance time was significantly increased in all subjects (from 510 ± 42 seconds to 676 ± 42 seconds during the first 3 months, P< 0.000001; and from 676 ± 42 seconds to 790 ± 45 seconds during the second 3 months of the program, P< 0.000001).  Changes in endurance time following the 6 months program were not significantly affected by the gender, pubertal status, or by the degree of obesity of the participants.

A combined dietary-behavioral-exercise intervention for childhood obesity resulted in a promising weight loss and BMI decrease. The program focused mainly on exercise training, nutritional education and changes in life-style, and only occasionally on providing strict hypocaloric menus.  The rational of our program design of two guided training sessions, an extra single self-guided physical activity and emphasis on nutritional education was that this kind of activity can be easily implemented into the daily lifestyle of the children, after they feel ready to leave our structured program. 

Long-term follow-up is still not available in our subjects.  However, multi-disciplinary pediatric programs have been more successful than adult programs in maintaining weight loss for 5 or 10 years.  Therefore, we believe that this model of weight management program for obese children may help to achieve the ultimate goal of long-term maintenance of BMI reduction.

University/Hospital:

Meir General Hospital, University of California