short and long term benefits.pdf

− Short- and Long-Term Beneficial Effects of a Combined Dietary

− Behavioral Physical Activity Intervention for the Treatment of Childhood Obesity Dan Nemet, Sivan Barkan, Yoram Epstein, Orit Friedland, Galit Kowen and Alon

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, Boulevard, and Elk trademarked Grove Village, by Illinois, the American 60007. Academy Copyright of © Pediatrics, 2005 by the 141 American Northwest Academy

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2005;115;e443 Pediatrics

DOI: 10.1542/peds.2004-2172

PEDIATRICS®

American Academy of Pediatrics

DEDICATED TO THE HEALTH OF ALL CHILDREN“

Short- and Long-Term Beneficial Effects of a Combined Dietary–Behavioral–Physical Activity Intervention for the Treatment of Childhood Obesity

Dan Nemet, MD*‡; Sivan Barkan, MSc, RD*‡; Yoram Epstein, PhD§; Orit Friedland, MD*‡; Galit Kowen, RD*‡; and Alon Eliakim, MD*‡

ABSTRACT. Background. Obesity has become the most common pediatric chronic disease in the modern era. Early prevention and treatment of childhood and adolescent obesity is mandated. Surprisingly, however, only a minor fraction of obese children participate in weight reduction interventions, and the longer-term ef- fects of these weight-reduction interventions among chil- dren have not been elucidated.

Objective. To examine prospectively the short- and long-term effects of a 3-month, combined dietary-behav- ioral-physical activity intervention on anthropometric measures, body composition, dietary and leisure-time habits, fitness, and lipid profiles among obese children. Methods. In this randomized prospective study, 24 obese subjects completed the 3-month intervention and were compared with 22 obese, age- and gender-matched, control subjects.

Results. At 3 months, there were significant differ- ences in changes in body weight ( 2.8 2.3 kg vs 1.2 2.2 kg), BMI ( 1.7 1.1 kg/m2 vs 0.2 1.0 kg/m2), body fat percentage (from skinfold tests; 3.3 2.6% vs 1.4 4.7%), serum total cholesterol level ( 24.6 15.1 mg/dL vs 0.8 18.7 mg/dL), low-density lipoprotein cholesterol level ( 23.3 15.2 mg/dL vs 3.7 17.3 mg/dL), and fitness (215 107 seconds vs 50 116 seconds) in the intervention group versus the control group. After a 1-year follow-up period, there were significant differ- ences between the intervention group (n 20) and the control group (n 20) in body weight (0.6 6.0 kg vs 5.3 2.7 kg), BMI ( 1.7 2.3 kg/m2 vs 0.6 0.9 kg/m2), and body fat percentage. There was a significant increase in leisure-time physical activity among the intervention participants, compared with a decrease among the control subjects.

Conclusions. Our data demonstrate the short- and longer-term beneficial effects of a combined dietary-be- havioral-physical activity intervention among obese chil- dren. These results highlight the importance of multidis- ciplinary programs for the treatment of childhood obesity and emphasize their encouraging long-term effects. Pediatrics 2005;115:e443–e449. URL: www.

pediatrics.org/cgi/doi/10.1542/peds.2004-2172; obesity, multidisciplinary treatment, childhood, exercise.

ABBREVIATIONS. LDL, low-density lipoprotein; TG, triglycer- ide; HDL, high-density lipoprotein. C

hildhood portions promote obesity has reached epidemic pro- worldwide, despite major efforts to weight reduction. The mechanisms responsible for the increasing prevalence of child- hood obesity are not understood completely, but lifestyle changes associated with increased caloric intake and decreased energy expenditure play prob- ably critical roles.1,2

Childhood obesity is associated with increased risk of hyperlipidemia, hypertension, insulin resis- tance, diabetes mellitus, and arteriosclerosis later in life.3,4 In addition, long-term follow-up results indi- cate that obese children and adolescents tend to be- come obese adults.5 Moreover, adults who were obese children have increased morbidity and mortal- ity rates independent of their adult weight.6 There- fore, prevention and treatment of obesity must start during childhood. It is surprising that relatively few intervention programs are available for obese chil- dren and adolescents and that treatment is initiated for 20% of obese children.7 Moreover, current data on the long-term effects of weight management pro- grams for childhood obesity are limited.

We previously reported the favorable immediate effects of a 3-, 6-, and 12-month multidisciplinary (nutritional, behavioral, and exercise) intervention on BMI and physical fitness among children and adolescents.8,9 The aim of the present study was to examine prospectively the long-term (1-year) effects of a brief (3-month), combined dietary-behavioral- physical activity intervention on body weight, BMI, BMI percentile, body composition, habitual physical activity, fitness, and serum lipids among obese Is- From the *Department of Pediatrics, Child Health and Sports Center, Meir General Hospital, Kfar-Saba, Israel; ‡Sackler School of Medicine, Tel Aviv

raeli children and adolescents.

University, Tel Aviv, Israel; and §Heller Institute for Research, Sheba Med- ical Center, Tel Hashomer, Israel.

METHODS Accepted for publication Nov 16, 2004. doi:10.1542/peds.2004-2172

Power Analysis

No conflict of interest declared.

The sample size calculation for this study was based on the Address correspondence to Dan Nemet, MD, Department of Pediatrics,

previously reported intervention changes in body weight and BMI Child Health and Sports Center, Meir General Hospital, 59 Tchernichovski

percentile among children.8 With a 2-sided, .05 significance level St, Kfar-Saba 44281, Israel. E-mail: nemet d@hotmail.com

in each group would allow us to detect a significant difference at emy of Pediatrics.

90% power. For BMI percentile, 11 subjects per group would be

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Exercise required to detect a significant difference with 90% power. We

Program chose to use the larger, weight change-based, sample size, which would provide adequate power for detecting both differences. To account for the expected dropout and loss of follow-up rates, assuming a higher dropout rate for the intervention group, we added 10 subjects to the intervention group and 6 subjects to the control group. We allocated intentionally an unequal number of participants to each group, on the basis of our previous experi- ence.8 In most cases, dropouts from our program (20%) were attributable to difficulties with transportation to our training fa- cility, whereas losses to follow-up monitoring (20%) were attrib- utable to relocation.

Fifty-four obese self-referred children and adolescents (6–16 years of age) participated in the study, with informed consent, from January 2002 to May 2003. The study was approved by the institutional review board of the Meir General Hospital. After recruitment, all participants were examined by the attending phy- sician at the Child Health and Sports Center. None of the subjects had an organic cause for his or her obesity, and none of the subjects received any medication that might interfere with growth or weight control (eg, corticosteroids or thyroid hormone).

Thirty children and adolescents were assigned randomly, with a computerized, random number generator, to participate in our 3-month, combined dietary and exercise program for the treat- ment of childhood obesity, at the Child Health and Sports Center,

All intervention subjects participated in a twice-weekly training program (1 hour per training session). Training was directed by professional youth coaches at the Child Health and Sports Center training center. The intervention was designed to mimic the type and intensity of exercise that elementary school and high school children perform normally. These activities 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 accounted for most of the time spent in training ( 50% team sports and 50% running games), with atten- tion to coordination and flexibility skills. The physicians who worked in the program (former members of the Israeli national track and field team) participated regularly in the training ses- sions, to encourage the children and provide examples.

To encourage personal responsibility among the participants, subjects were instructed to add an extra 30 to 45 minutes of walking or other weight-bearing sport activities at least once per 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 sedentary activities (eg, reduce television view- ing and video game use, use stairs instead of elevators, and play outside instead of inside).

Meir General Hospital, Tel Aviv University. During the interven- tion period, 6 subjects (20%) withdrew from the program (mainly because of difficulties with transportation to the exercise training facility). Twenty-four subjects completed the 3-month program, and 20 of them returned for evaluation 1 year later.

Twenty-four obese children and adolescents were assigned to serve as control subjects and were monitored in our pediatric obesity clinic. Control subjects were referred to an ambulatory nutritional consultation at least once and were instructed to per- form physical activity 3 times per week on their own. Twenty-two control subjects completed the 3-month evaluation, and 20 of them returned for evaluation after 1 year.

Anthropometric Measurements

Standard calibrated scales and stadiometers were used to de- termine height, weight, and BMI. Because BMI changes with age, BMI-for-age percentiles were calculated according to the Centers for Disease Control and Prevention growth charts,10 with the following equation: C M(1 LSZ)2(1/L), where C represents the age (in months)-adjusted percentile for a given measurement (eg, BMI), M represents the age-related median, S represents the age- related SD, L represents the age-related power in the Box-Cox transformation, and Z represent the z score.

The age-adjusted z score corresponding to the exact percentile for a given measurement was calculated with the following equa- Intervention Design

tion: Z [(X/M)2L 1]/LS, where X represents the physical measurement (eg, weight, length, head circumference, stature, or Subjects and parents in the intervention group were invited

calculated BMI value) and the L, M, and S values were again together for a series of 4 evening lectures (on childhood obesity,

collected from the appropriate table corresponding to the age (in general nutrition, a therapeutic nutritional approach for childhood

months) of the child. Measurements were performed weekly obesity, and exercise and childhood obesity) during the 3 months

throughout the 3-month program and again 1 year after the inter- of the program. The lectures were given by the physicians and

vention. dietitian of the Child Health and Sports Center.

Triceps and subscapular skinfold values were measured to the nearest 0.1 mm, with Holtain skinfold calipers (CMS Weighing Equipment, Crymych, United Kingdom). Measurements were Dietary Intervention

made on the right side of the body. All measurements (baseline, 3 The participants met with the dietitian 6 times during the 3-month program. The participants in these meetings differed according to the age of the patients. For children 6 to 8 years of

months, and 1 year) were performed by the same trained individ- ual. Calculations of percentage body fat were performed with standard equations.11 age, only the parents were invited for the first 2 meetings, and the children joined the meetings thereafter. Children 8 years of age were invited, with both parents, to all meetings. Pubertal subjects were invited to the first meeting with both parents and than, alternately, the adolescent and his or her parents met the dietitian separately. Each family was instructed to come to the first meeting with a 24-hour dietary recall. The first appointment, which was 45 to 60 minutes long, was dedicated to becoming acquainted, learn- ing about the reasons for childhood obesity, receiving information about food choices and dietary and cooking habits, understanding the motivation for weight loss, and trying to enroll the whole family in the “battle” against overweight. The subsequent ap- pointments, which were 30 to 45 minutes each, were devoted mainly to nutritional education (eg, food pyramid, food choices, food labels, food preparation and cooking, eating habits, regular meals, and controlling environments that stimulate overeating). In addition, children received dietary information through work- sheets and flyers on important nutritional issues such as the food

Nutritional Assessment

All subjects were instructed on how to keep a 2-day food record and were evaluated for understanding and accuracy through ad- ministration of a 24-hour recall before initiation of the study. Subjects kept three 2-day food records (at baseline, at the end of the 3-month program, and 1 year later). The food record data were reviewed by the project nutritionist and checked for omissions (for example, whether dressing was used on a salad listed as ingested with no dressing) and errors (for example, inappropriate portion size). This approach was validated by Crawford et al12 for children and adolescents. All subjects completed the baseline, 3-month, and 1-year food records.

Food records were analyzed with the Israeli Ministry of Health tables. A computer algorithm based on these tables calculated the total energy intake and the proportions of the total energy intake derived from protein, fat, and carbohydrates. pyramid, fruits and vegetables, calcium intake and needs, special dietary consideration during holidays, and how to deal with food during a big celebration, on vacations, and at restaurants.

Habitual Activity Assessment Subjects received a balanced hypocaloric diet. The diet con-

Habitual physical activity was assessed with a physical activity sisted of 5021 to 8368 kJ (depending on the age and weight of the

questionnaire.13 Each type of activity was scored according to an child), a caloric deficit of 30% from the reported intake, or intake

estimated metabolic equivalent score, and a final weighted score 15% less than the estimated daily required intake.

was calculated.

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Three-Month Fitness Assessment

Intervention Fitness was assessed with a progressive treadmill exercise test,

After the 3-month intervention, there were signif- to determine exercise endurance.8 Subjects performed an exercise test before the program, at the end of the 3-month program, and 1 year after the program, with the same protocol. All subjects were familiarized with the treadmill for 5 minutes and performed a warm-up of 1 minute at a speed of 2.2 miles per hour, with no

icant decreases in body weight (from 63.8 19.1 kg to 61.0 18.3 kg), BMI (from 28.5 4.1 kg/m2 to 26.8 3.9 kg/m2), and body fat percentage (from 40.2 7.3% to 36.9 8.0%) among the intervention partic- incline. Exercise started at a speed of 2.2 miles per hour, with an incline of 10 degrees. The exercise intensity was enhanced every 2 minutes by increasing the elevation of the treadmill by 2.5 degrees (up to an incline of 22.5 degrees). Then the treadmill speed was increased by 0.6 miles per hour every 2 minutes. All subjects were

ipants (Fig 1). In contrast, there were significant in- creases in body weight (from 63.4 22.8 kg to 64.5 24.1 kg) and body fat percentage (from 40.7 7.9% to 42.2 9.9%) among the control subjects, whereas encouraged throughout the test by the staff members and exer- cised to the limit of their tolerance. Endurance time was measured from the end of the warm-up period to exhaustion.

BMI was not changed (from 27.8 5.0 kg/m2 to 27.6

5.6 kg/m2). Changes in habitual physical activity, screen time

Evaluation of Serum Lipid Levels

(television and computer), and fitness among the intervention participants and control subjects are Early-morning blood samples were collected for all subjects after a fast of 12 hours. Samples were collected at baseline and after the 3-month intervention. Serum total cholesterol, triglycer- ide (TG), and high-density lipoprotein (HDL) cholesterol levels were analyzed with an automated instrument (Hitachi 747; Boehr-

summarized in Table 2. There was a significant in- crease in the habitual physical activity index after the intervention, compared with a small decrease among the control subjects. Endurance time increased sig- inger Mannheim, Mannheim, Germany). Low-density lipoprotein (LDL) cholesterol levels were calculated for samples containing TG levels of 400 mg/dL, with the following equation: LDL total cholesterol HDL (TG/5). Cholesterol levels of 170 mg/dL were defined as acceptable, 170 to 199 mg/dL as border- line, and 200 mg/dL as elevated. LDL cholesterol levels of 110

nificantly in both groups, but the increase in the intervention group was significantly greater. Screen time did not change significantly for the intervention and control subjects.

Changes in daily energy intake and relative intake mg/dL were defined as acceptable, 110 to 129 mg/dL as border- line, and 130 mg/dL as elevated.14

from carbohydrates, protein, and fat among the in- tervention participants and control subjects are sum-

Statistical Analyses

marized in Table 3. Both groups reported significant decreases in daily energy intake, but there was no Two-sample t tests were used to determine baseline differences between the control and intervention groups. Two-way, repeated- measures, analyses of variance were used to compare effects on body weight, BMI, percentage body fat (from skinfold measure- ments), habitual physical activity, fitness, and body lipid levels

significant difference between the groups.

After the 3-month intervention, there were signif- icant decreases in total cholesterol and LDL choles- terol levels (Table 4). There was no significant differ- between the intervention subjects and the control subjects, with time serving as the within-group factor and intervention as the between-group factor. Statistical significance was taken at P .05. Data are presented as mean SD.

ence in the changes in serum TG and HDL cholesterol levels between the intervention partici- pants and the control subjects.

RESULTS

Long-Term (1-Year) Effects

Twenty subjects in each group completed the Subject Characteristics

1-year follow-up evaluation. Changes in anthropo- Subject characteristics are summarized in Table 1.

metric measurements, energy intake, leisure-time ac- No significant differences in age, gender, pubertal

tivities, and fitness are summarized in Table 5. One status (overall and gender specific), BMI, body fat,

year after the combined dietary-behavioral-physical television viewing, habitual physical activity, fitness,

activity intervention, there were significant decreases and parental obesity were found between the groups

in BMI and body fat percentage among the interven- before the combined dietary and exercise interven-

tion participants, compared with increases among tion (Table 1).

the control subjects. Body weight was maintained

TABLE 1. Characteristics of the Study Participants

Control Subjects (n 22)

Intervention Subjects (n 24)

Age, y 11.3 2.8 10.9 1.9 Gender, male/female 12/10 14/10 Pubertal status, Tanner stage 2.6 2.0 2.2 1.5 Male/female Tanner stage 2.1 1.7/3.0 1.6 2.0 1.3/2.4 1.6 Height, m 1.485 0.16 1.477 0.12 Weight, kg 63.4 22.8 63.8 19.1 BMI, kg/m2 27.8 5.0 28.5 4.1 Body fat (skinfold), % 40.7 7.9 40.2 7.3 Caloric intake, kJ/d 8335 1741 7519 1569 Screen time, h/d 4.6 4.2 4.8 1.6 Habitual activity, units 24.3 20.1 22.5 12.5 Endurance time, s 597 128 660 184 Parental obesity, both/single/none, no 7/11/4 8/10/6

No significant differences were found between the groups before the intervention.

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Fig 1. Short-term (3-month) body weight, BMI, and skinfold thick- ness changes in the intervention and control groups. There were significant differences in all 3 outcome variables (*P .05).

among the intervention participants, compared with a significant increase among the control subjects.

Habitual physical activity was significantly in- creased among the intervention participants. There was a greater increase in fitness level among the intervention participants; however, this difference did not reach statistical significance (P .056). Both groups reported decreased screen time, but there was no between-group difference. No adverse events were noted during the intervention.

DISCUSSION This study demonstrates the short-term (3 months) and long-term (1 year) beneficial effects of a com- bined nutritional-behavioral-exercise intervention for childhood obesity. Our intervention was associ- ated with significant weight loss, reduced BMI, re- duced body fat, increased habitual physical activity, and improved fitness, as well as reduced total and LDL cholesterol levels, among obese children and adolescents. In contrast, obese children who did not participate in the intervention program gained weight, increased their body fat percentage, did not change their habitual physical activity level, and had

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a lesser improvement in fitness. Favorable effects on body weight, BMI, body fat, and habitual physical activity were maintained among the intervention participants, compared with the control subjects, af- ter a 1-year follow-up period.

Childhood obesity has reached epidemic propor- tions in recent years, and the prevalence of childhood obesity in Israel is among the highest, compared with European countries and the United States.15 Despite the increased prevalence, very few treatment pro- grams for childhood obesity are available, and 20% of obese children initiate treatment. Treatment pro- grams for childhood obesity require a multidisci- plinary approach and should include dietary changes, nutritional education, changes in physical activity patterns, behavioral modification, and pa- rental involvement.16,17 Pediatric weight manage- ment programs should emphasize realistic goals. Weight loss should be encouraged only in severe obesity, whereas maintenance of body weight with continued linear growth, accompanied by develop- ment of a healthier lifestyle, should be the goal for the majority of obese children. Moreover, because BMI increases naturally with age (eg, the 95th per- centile for girls is 20.6 kg/m2 at the age of 8 years and 28.9 kg/m2 at the age of 16 years,18 maintenance of BMI, and in some cases even attenuation of the in- crease in BMI, could be considered a success. In this study, 90% of the intervention participants reduced their BMI, whereas BMI kept increasing for 68% of the control subjects.

Today’s children’s sedentary lifestyle and the in- creased inactivity in western societies are among the major contributors to the increased prevalence of childhood obesity.19,20 Therefore, exercise training and education represented the major focus of our intervention. As a result, leisure-time physical activ- ity increased significantly and fitness improved for all intervention participants. It is interesting to note that the 3-month program was not associated with a significant decrease in television viewing or com- puter game time. It can be assumed that an addi- tional decrease in physical inactivity among the in- tervention participants is possible and may lead to greater weight loss and better improvement in phys- ical fitness.

We and others demonstrated previously21 that el- evated total and LDL cholesterol levels are relatively common among obese children and adolescents. This suggests that obesity should be considered a risk factor for pediatric hypercholesterolemia and that obese children should be screened for abnormal lipid profiles. The clinical implications of hypercholester- olemia among obese children and adolescents are becoming better understood. It is now known that elevated cholesterol levels during childhood are as- sociated with hypercholesterolemia in adult life.22,23 Moreover, lipid abnormalities among children and adolescents are related to higher risks of insulin re- sistance and hypertension later in life and play an important role in the development of heart disease. Therefore, one of the most important findings of this study was the significant decrease in serum choles- terol and LDL cholesterol levels among the interven-

ii Intervention

Control

Skinfold Thickness (mm)

BMI Change (Kg/m2)

Body Weight Change (Kg)

TABLE 2. Short-Term (3-Month) Changes in Habitual Physical Activity, Screen (Television and Computer) Time, and Fitness Among the Intervention Participants and Control Subjects

Control Group Intervention Group

Before After Before After

Screen time, h/d 4.5 4.2 4.2 1.6 4.8 1.6 4.1 1.7 Habitual activity, units 24.3 20.1 22.1 16.9 22.5 12.5 45.7 12.6* Endurance time, s 597 128 642 148 660 184 821 110*

Data are presented as mean SD. * P .05 for between-group difference.

TABLE 3. Short-Term (3-Month) Changes in the Daily Caloric Intake and the Relative Contribu- tions of Carbohydrates, Protein, and Fat Among the Intervention Participants and Control Subjects

Control Group Intervention Group

Before After Before After

Caloric intake, kJ/d 8335 1741 6602 1439* 7519 1569 5887 1305* Carbohydrate, g 271 68 218 47* 224 48 171 40* Protein, g 72 15 62 19 74 21 75 20 Fat, g 80 22 62 21* 74 21 59 22*

Data are presented as mean SD. * P .05 for within-group difference.

TABLE 4. Short-Term (3-Month) Changes in Serum Lipid Levels Among the Intervention Partic- ipants and Control Subjects

Control Group Intervention Group

Before After Before After

TGs, mg/dL 109.8 42.4 104.3 52.7 93.6 29.5 79.7 32.5 Cholesterol, mg/dL 165.2 29.2 167.1 20.4 170.1 22.5 147.8 19.3* HDL cholesterol, mg/dL 44.1 10.7 45.5 12.0 43.6 7.2 44.8 8.4 LDL cholesterol, mg/dL 101.9 26.7 99.9 18.0 106.5 20.0 89.7 17.0*

Data are presented as mean SD. * P .05 for between-group difference.

TABLE 5. Long-Term Changes in Anthropometric Measurements, Leisure Time Activities, and Fitness After 1 Year of Follow-Up Monitoring

Control Group (n 20) Intervention Group (n 20)

Before 12 Months Before 12 Months

Height, m 1.476 0.16 1.520 0.15* 1.445 0.11 1.490 0.10* Weight, kg 63.4 23.6 68.6 24.8 59.1 15.4 59.7 17.7† BMI, kg/m2 28.0 5.2 28.6 5.8 27.7 3.6 26.1 4.7† BMI percentile 97.2 0.7 96.1 1.4 98.2 0.3 92.3 3.0† Body fat, % 40.9 9.5 44.4 9.7 40.6 6.7 38.3 12.5† Caloric intake, kJ/d 8318 1661 7736 3088 7878 1778 5908 1573 Screen time, h/d 4.7 1.7 3.4 1.7* 4.6 1.7 3.3 1.2* Habitual activity, units 26.2 20.0 18.9 14.4 25.0 12.4 34.1 21.1† Endurance time, s 629.0 128.1 669.3 157.8 614.7 184.2 799.8 167.2†

Data are presented as mean SD. * P .05 for within-group difference. † P .05 for between-group difference.

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pediatrics.aappublications.org www.pediatrics.org/cgi/doi/10.1542/peds.2004-2172 at Eccles Health Sciences Lib on September 12, 2011 e447 tion participants. This highlights the importance of

concomitant decrease in the habitual activity levels multidisciplinary programs for the treatment of

for the control group was reported during the inter- childhood obesity, not only for weight reduction and

vention period; therefore, reduced activity could not changes in body composition but also for improve-

account for this weight increase. It is possible that the ment of lipid profiles and reduction of risk factors for

subjectivity of the food-recording techniques was a atherosclerosis.

source of error. A number of investigators think that An interesting finding of this study was that both

under-recording of self-reported food intake occurs control and intervention participants reported a de-

often24,25 and that participation in a weight manage- crease of 1674 kJ/day after the 3-month observa-

ment study (even if “only” as control subjects) leads tion period. However, the intervention participants

to subconscious underestimation/underreporting of lost weight but the control subjects kept gaining

the daily total energy intake. weight during the observation period. The explana-

Adult studies indicate that the long-term effects of tion for this discrepancy is not completely clear. No

weight reduction programs have been very disap-

pointing.26 In this study, the favorable short-term effects of the combined dietary-behavioral-physical activity intervention remained significant 1 year after the intervention. The intervention participants dem- onstrated remarkable decreases in BMI, age-adjusted BMI percentile, and body fat and substantial in- creases in habitual activity and fitness level 1 year after the end of active intervention.

A mean decrease in age-adjusted BMI percentiles of 5% to 6% is very impressive and indicates that some of the obese children and adolescents were not categorized as obese after the 1-year follow-up pe- riod, whereas many with marked obesity (BMI of 95th percentile) were reclassified as overweight (BMI of 85th to 95th percentile). Moreover, obesity is frequently complicated by abnormal lipid profiles, insulin resistance, and hypertension.27 Many of these associated complications can be reversed with a 5% decrease in age-adjusted BMI percentile.28 Unfortu- nately, the majority of our intervention participants refused to undergo blood testing at the 1-year fol- low-up evaluation; therefore, we were unable to as- sess whether the short-term positive effects of the intervention on body lipids lasted.

Interestingly, the decreases in BMI percentile at the 1-year follow-up evaluation after the 3-month inter- vention were very similar to the changes we reported recently for a different group of obese children and adolescents who participated in 12 consecutive months of a similar structured program9 (Fig 2). Our brief program focuses mainly on exercise training, nutritional education, and behavioral changes and therefore can be implemented easily in the daily lives of children. Once the children gained the basic knowledge and health-related skills (presumably af- ter 3 months), they were able to maintain their achievements on their own after 1 year.

Finally, the fitness improvement of the interven- tion participants 1 year after the intervention was greater than that of the control subjects; this differ- ence almost reached statistical significance (P .056). The improved fitness resulted probably from the greater habitual activity of the intervention par-

Fig 2. Changes in BMI percentiles among study participants. Data were compared with a different group of obese children who participated in a 1-year combined program in our center.9 There was a significant decrease in BMI percentiles in intervention ver- sus control subjects.

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ticipants, compared with the control group subjects. This might be very important because increased physical fitness, even without weight loss, can im- prove insulin sensitivity and lipid profiles, reduce blood pressure, and reduce the risk of heart disease later in life.29

CONCLUSIONS Our brief multidisciplinary intervention resulted in significant positive effects on body weight, BMI, body fat, habitual activity, fitness, and body lipids. Moreover, the participants’ ability to incorporate easily the intervention principles into their daily activities helped them to maintain most of their achievements at the 1-year follow-up evaluations. Additional studies are needed to assess longer-term (eg, 5-year) effects of this intervention. Encourag- ingly, however, multidisciplinary pediatric pro- grams seem to be more successful than adult pro- grams in maintenance of weight loss for 5 or 10 years.30,31

ACKNOWLEDGMENT This work was supported by a grant from the Israeli Heart Fund.

REFERENCES

1. Hancox RJ, Milne BJ, Poulton R. Association between child and adoles- cent television viewing and adult health: a longitudinal birth cohort study. Lancet. 2004;364:257–262 2. Dietz WH. Overweight in childhood and adolescence. N Engl J Med.

2004;350:855–857 3. Berenson GS, Srinivasan SR, Bao W, Newman WP III, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk fac- tors and atherosclerosis in children and young adults: the Bogalusa Heart Study. N Engl J Med. 1998;338:1650–1656 4. Mossberg HO. 40-year follow-up of overweight children. Lancet. 1989;

2:491–493 5. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337:869–873 6. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term mor- bidity and mortality of overweight adolescents: a follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992;327: 1350–1355 7. Denen ME, Hennessey JV, Markert RJ. Outpatient evaluation of obesity in adults and children: a review of the performance of internal medicine/pediatrics residents. J Gen Intern Med. 1993;8:268–270 8. Eliakim A, Kaven G, Berger I, Friedland O, Wolach B, Nemet D. The effect of a combined intervention on body mass index and fitness in obese children and adolescents: a clinical experience. Eur J Pediatr. 2002;161:449–454 9. Eliakim A, Friedland O, Kowen G, Wolach B, Nemet D. Parental obesity and higher pre-intervention BMI reduce the likelihood of a multidisci- plinary childhood obesity program to succeed: a clinical observation. J Pediatr Endocrinol Metab. 2004;17:1055–1061 10. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11. 2002;(246):1–190 11. Slaughter MH, Lohman TG, Boileau RA, et al. Skinfold equations for estimation of body fatness in children and youth. Hum Biol. 1988;60: 709–723 12. Crawford PB, Obarzanek E, Morrison J, Sabry ZI. Comparative advan- tage of 3-day food records over 24-hour recall and 5-day food frequency validated by observation of 9- and 10-year-old girls. J Am Diet Assoc. 1994;94:626–630 13. Godin G, Shephard RJ. A simple method to assess exercise behavior in

the community. Can J Appl Sport Sci. 1985;10:141–146 14. Shamir R, Lerner A, Fisher EA. Hypercholesterolemia in children. Isr

Med Assoc J. 2000;2:767–771 15. Lissau I, Overpeck MD, Ruan WJ, Due P, Holstein BE, Hediger ML.

— 3 month intervention

Conn-0| 12 month intervention

One Year

and Body mass index and overweight in adolescents in 13 European coun-

the effect of exercise training on the dietary intake of healthy tries, Israel, and the United States. Arch Pediatr Adolesc Med. 2004;158:

adolescents. Int J Obes Relat Metab Disord. 1998;22:354–362 27–33

25. Bingham SA. Limitations of the various methods for collecting dietary 16. Goran MI, Reynolds KD, Lindquist CH. Role of physical activity in the

intake data. Ann Nutr Metab. 1991;35:117–127 prevention of obesity in children. Int J Obes Relat Metab Disord. 1999;

26. Crawford D, Jeffery RW, French SA. Can anyone successfully control 23(suppl 3):S18–S33

their weight? Findings of a three year community-based study of men 17. Williams CL, Campanaro LA, Squillace M, Bollella M. Management of childhood obesity in pediatric practice. Ann NY Acad Sci. 1997;817: 225–240 18. Rosner B, Prineas R, Loggie J, Daniels SR. Percentiles for body mass

index in U.S. children 5 to 17 years of age. J Pediatr. 1998;132:211–222 19. Sothern MS. Obesity prevention in children: physical activity and nu-

trition. Nutrition. 2004;20:704–708 20. Marshall SJ, Biddle SJ, Gorely T, Cameron N, Murdey I. Relationships between media use, body fatness and physical activity in children and youth: a meta-analysis. Int J Obes Relat Metab Disord. 2004;28:1238–1246 21. Friedland O, Nemet D, Gorodnitsky N, Wolach B, Eliakim A. Obesity and lipid profiles in children and adolescents. J Pediatr Endocrinol Metab. 2002;15:1011–1016

and women. Int J Obes Relat Metab Disord. 2000;24:1107–1110 27. Steinberger J, Daniels SR. Obesity, insulin resistance, diabetes, and cardiovascular risk in children: an American Heart Association scien- tific statement from the Atherosclerosis, Hypertension, and Obesity in the Young Committee (Council on Cardiovascular Disease in the Young) and the Diabetes Committee (Council on Nutrition, Physical Activity, and Metabolism). Circulation. 2003;107:1448–1453 28. Reinehr T, Andler W. Changes in the atherogenic risk factor profile according to degree of weight loss. Arch Dis Child. 2004;89:419–422 29. Carnethon MR, Gidding SS, Nehgme R, Sidney S, Jacobs DR Jr, Liu K. Cardiorespiratory fitness in young adulthood and the development of cardiovascular disease risk factors. JAMA. 2003;290:3092–3100 22. Belay B, Belamarich P, Racine AD. Pediatric precursors of adult athero-

30. Epstein LH, Valoski AM, Kalarchian MA, McCurley J. Do children lose sclerosis. Pediatr Rev. 2004;25:4–16

and maintain weight easier than adults: a comparison of child and 23. Lauer RM, Lee J, Clarke WR. Factors affecting the relationship between

parent weight changes from six months to ten years. Obes Res. 1995;3: childhood and adult cholesterol levels: the Muscatine Study. Pediatrics.

411–417 1988;82:309–318

31. Epstein LH. Methodological issues and ten-year outcomes for obese 24. Ambler C, Eliakim A, Brasel JA, Lee WN, Burke G, Cooper DM. Fitness

children. Ann NY Acad Sci. 1993;699:237–249

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− Short- and Long-Term Beneficial Effects of a Combined Dietary

− Behavioral Physical Activity Intervention for the Treatment of Childhood Obesity Dan Nemet, Sivan Barkan, Yoram Epstein, Orit Friedland, Galit Kowen and Alon

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