Effective for Controlling Childhood Obesity and the Associated Cardiometabolic Risk Factors?

Objectives:This study was conducted to assess the effectiveness of a simple office-basedprogram for encouraging healthy lifestyle on controlling childhood obesity and associated cardiometabolic risk factors.

Methods:This non-randomized 24-week lifestyle modification trial was conducted among 457obese children and adolescents, aged 2e18 years, who had at least one cardiometabolic riskfactor in addition to obesity. This trial included three components of exercise, diet educationand behavior modification, with all recommendations provided by a pediatrician, two generalphysicians and a nurse. Instead of strict inhibitory recommendations, healthier lifestyle wasencouraged.

Results:Overall 448 (98.04%) of enrolled children completed the trial with a mean age of9.6±2.9 years. After the trial, the mean of anthropometric measures and cardiometabolic riskfactors decreased significantly, the mean high-density lipoprotein cholesterol (HDL-C)increased significantly, and the prevalence of the metabolic syndrome decreased from 20.8% to 1.8%. Triglycerides, LDL-C, diastolic blood pressure and WC had the highest decrease in allage groups, with the most prominent changes in the 14e18-year age group. By each -1SDdecline in BMI and WC, risk factors had significant improvement.

Conclusion:Motivational office-based counseling can be effective in treatment of childhoodobesity and its associated cardio-metabolic risk factors. Such approach can be implementedin the primary health care system; and can be of special concern in low- and middle-incomecountries with limited human and financial resources. We suggest that expanding the rolesof non-physician clinicians such as nurse practitioners can help to increase the amount of timeavailable for such services.

Copyright©2012, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rightsreserved.

1. Introduction

The escalating trend of childhood obesity has tremendousimplications for the risk of chronic diseases later in life. Theclustering of cardiometabolic risk factors in obese childrenand adolescents is an important contributor to theincreased risk of prediabetes, type 2 diabetes and cardiovascular diseases.1Metabolic syndrome (MetS), a commonpathophysiological condition with implications in thedevelopment of chronic diseases, is becoming a publichealth problem even in children and adolescents of developing countries.2It is therefore extremely important thatchildhood obesity is prevented and treated by simple andfeasible methods. Healthy lifestyle remains the mainstay ofweight control and is recommended as the first-line intervention for controlling excess weight and MetS amongchildren and adolescents.

The two most important modifiable determinants of bodyweight are healthy diet and physical activity, which caninfluence excess weight and some of its cardiometabolicconsequences.3,4This association has been documented indifferent ethnic groups.

Results of residential programs7,8and trials includingsupervised physical exercise9have been satisfactory incontrolling weight and related cardiometabolic risk factorsamong youths; however such programs might be not accessible for children and adolescents with various economic andsocio-cultural backgrounds in different community settings.Furthermore, given that the common forms of childhoodobesity seem to result from a predisposition that primarilyfavors obesogenic behaviors in an obesogenic environment,10no program can be sustainable without involvementof families in the process of controlling childhoodoverweight.

It is suggested that office-based comprehensive multidisciplinary intervention, even of low intensity, can beeffective in motivating and promoting health to obesechildren and families.Such experience is limited in mostdeveloping countries, and to the best of our knowledge, noprevious similar study has been conducted in the EasternMediterranean region. We aimed to assess the effectivenessof a simple office-based program, feasible for integrationinto a primary healthcare system, for encouraging healthylifestyle on controlling excess weight and associated cardiometabolic risk factors among obese children andadolescents in Isfahan, Iran.

2. Methods

2.1. Study population

This nonrandomized trial was conducted among 457 obesechildren and adolescents, i.e., with a body mass index (BMI)equal to or greater than the 95thpercentile, who were aged2e18 years, and had at least one cardiometabolic riskfactor in addition to obesity. Participants were consecutively recruited from among 725 obese children andadolescents who were referred from October 2007 to June2008 to the Obesity and Metabolic Syndrome ResearchClinic of the Pediatric Preventive Cardiology Department,Isfahan Cardiovascular Research Center (ICRC), a WorldHealth Organization (WHO) collaborating center. They werereferred from schools and healthcare centers, as well aspublic and private offices of all parts of the city withdifferent socio-demographic characteristics. Those individuals with syndromal obesity, mental retardation, signs orsymptoms of endocrine disorders, presence of any physicaldisability, and/or history of chronic medication use werenot included in the survey.

The study was approved by the Ethics Committee of ICRC(NIH Code: FWA 0000t8578). All parents of included childrengave written informed consent after receiving informationabout the trial, and oral assent was obtained fromparticipants.

2.2. Physical examination

All measurements were made by the same trained team ofgeneral physicians and nurses under the supervision of thesame pediatrician, by using calibrated instruments andfollowing standard protocols.

The age of participants was recorded according to theirbirth date. Height (Ht) and weight (Wt) were measuredtwice to ±0.2 cm and to ±0.2 kg, respectively, with subjectsbeing barefoot and lightly dressed; the averages of thesemeasurements were recorded. BMI (weight in kilogramsdivided by the square of height in meters) was calculated.Waist circumference (WC) was measured with a nonelastictape at a point midway between the lower border of the ribcage and the iliac crest at the end of normal expiration.

Blood pressure (BP) was measured using mercurysphygmomanometers after 5 minutes of rest in the sitting position. The subjects were seated with the heart, cuff andzero-indicator on the manometer at the level of theobserver’s eye. All readings were taken in duplicate in theright arm. Appropriate size cuffs were used with cuff-width 40% of mid-arm circumference, and cuff bladders covering 80% to 100% of the arm circumference and approximatelytwo-thirds of the length of the upper arm without overlapping. The procedure was explained to the children andthe cuff inflated and deflated once, the first BP measuredwas not used in the analysis of this study. The readings atthe first and the fifth Korotkoff phase were taken as systolicand diastolic BP (SBP and DBP), respectively. The averageof the two BP measurements was recorded and included inthe analysis.

2.3. Biochemical analysis

The children were instructed to fast for 12 hours before thescreening; compliance with fasting was determined byinterview on the morning of examination. Each child wasaccompanied by one of their parents while blood sampleswere taken from the antecubital vein between 8:00AM and 9:30AM.

All laboratory measurements were performed in ICRCcentral laboratory with adherence to external national andinternational quality control. The blood samples werecentrifuged for 10 minutes at 3000 rpm within 30 minutes ofvenipuncture. Fasting blood sugar (FBS), total cholesterol(TC), low-density lipoprotein-cholesterol (LDL-C), highdensity lipoprotein-cholesterol (HDL-C) and triglycerides(TG) were measured enzymatically by auto-analyzer(Hitachi, Tokyo, Japan). HDL-C was determined afterdextran sulfate-magnesium chloride precipitation of nonHDL-C.

2.4. Definition of cardiometabolic risk factors

Abnormal serum lipids were defined as a TC, LDL-C and or TG higher than the level corresponding to the age- andgender-specific 95th percentile, as well as HDL-C lowerthan age- and gender-specific fifth percentile. MetS wasdefined based on criteria analogous to Adult TreatmentPanel III (ATP III) modified for children and adolescents as three or more of the following: fasting TG≥100 mg/dL,HDL-C<50 mg/dL (except in boys aged 15-18 years, inwhom the cut-off was</45 mg/dL), WC>75th percentilefor age and gender in the population studied16; SBP and/orDBP>/90thpercentile for gender, age and height from theNational Heart, Lung and Blood Institute’s recommendedcut-off point12and FBS≥/100 mg/dL. It should be notedthat the modified ATP III definition15used the cut-off of FBS≥/110 mg/dL, but similar to our previous national study,6we used the last recommendation of the American Diabetes Association.

2.5. Intervention

This 24-week lifestyle modification trial, which was carriedout with the same method for all participants, includedthree components of exercise, diet education and behaviormodification.

To be feasible for integration into a primary healthcaresystem, all recommendations were provided by a teamconsisting of a pediatrician, two general physicians anda nurse. Instead of strict inhibitory recommendationssometimes provided for controlling overweight, we tried toencourage children and families to follow a healthier lifestyle. We used face-to-face education for each participantand their accompanying parent, who was usually themother. First, simple rules of controlling overweight wereadvised to children and parents simultaneously, and it wasemphasized that as in adults, there is no quick and easy wayfor children and adolescents to lose weight, and thathealthy lifestyle is the mainstay of weight loss. For furtherencouragement of participants, this fact was accentuatedthat contrary to adults, children and adolescents aregrowing and by getting taller, they can reach ideal bodyweight much easier than adults can. The first realistic goalwas described as to stop gaining weight, but given thatparticipants had cardiometabolic disorder, the optimal goalwas defined as gradual weight loss to achieve a healthierBMI. Then, the importance of following a combination ofdecreasing the amount of energy intake and energyexpenditure was explained. Given that our national studyrevealed that the main problems in families’ dietary habitswere overconsumption of carbohydrates (mostly whitebread, rice and potato), frequent use of deep-fried foods,using hydrogenated solid fats rich in trans fatty acids,frequent use of sweet/salty/fat snacks,6,18we focused ourrecommendations to improve these unhealthy habits.

Parents were asked not to sensitize their children bytalking to them too much about reducing the calorie intake,and instead, offer a healthy diet without skipping the threemain meals (especially breakfast) and with healthy snacks,and allowing occasional treats. For dietary recommendations to children, we used the term “eat” for healthy foods,instead of using “don’t eat” for unhealthy choices. Forinstance we recommended: “eat breakfast”, “eat vegetables”, “eat salads”, “eat nonfried foods”, “eat beans”,“eat fruits instead of potato chips” etc. In addition wetrained children to increase their physical activity on theoccasions they used high-calorie foods such as sweets, fastfoods, soft drinks etc.

For increasing daily physical activity, first we askedparticipants to reduce their sedentary habits notablylimiting the time spent on watching television and playingcomputer and video games to less than 2 hours a day. Thenwe encouraged them to take regular daily exercise andphysical activities they enjoyed, beginning with lowintensity activities of short duration and graduallyincreasing the intensity and duration. We asked parents tojoin in with their children’s physical activities as much aspossible.

For increasing daily physical activity, first we askedparticipants to reduce their sedentary habits notablylimiting the time spent on watching television and playingcomputer and video games to less than 2 hours a day. Thenwe encouraged them to take regular daily exercise andphysical activities they enjoyed, beginning with lowintensity activities of short duration and graduallyincreasing the intensity and duration. We asked parents tojoin in with their children’s physical activities as much aspossible.

In addition, we informed participants that we wouldorganize a festival to celebrate and reward children whohave been successful in weight loss, while encouragingother overweight children and families.

The first face-to-face education for each participantlasted for about 15 minutes; thereafter families and children participated voluntarily in group discussions to sharetheir experiences on weight control. All participants andtheir parents were followed up by monthly telephone callfor 6 months, and were invited to the clinic every 2 months.During the follow-up visits, participants and their parentswere encouraged to follow the healthy lifestyle recommendations, and any related questions that they had wereanswered. Anthropometric measurements were repeated,and the results including positive or negative changeswere provided to participants. Those who had a raisedBMI were encouraged to intensify their healthy habits, andwere reassured that by following the recommended simplerules, they could achieve a healthier BMI. After 6 months,all participants were recalled to the clinic to repeat thephysical and biochemical examinations.

2.6. Statistical analysis

Data were analyzed by SPSS version 16.0 (SPSS Inc., Chicago, USA). Descriptive data were expressed as meanvalues
standard deviations (SD) for continuous variables.Paired Studentttest and Chi-square tests were used tocompare variables before and after the trial. Regressionanalysis was conducted for the change in cardiometabolicrisk factors per one SD decline in BMI and WC according togender and age groups.

3. Results

Overall 448 (98.04%) of enrolled children and adolescentscompleted the trial, consisting of 261 (58.3%) girls and 187(41.7%) boys. The mean age of participants was 9.6±2.9years without difference in terms of gender. Participantsconsisted of 34 (22 girls, 12 boys) in the 2-5.9-year agegroup, 198 (118 girls, 80 boys) in the 6-9.9-year age group,166 (93 girls, 73 boys) in the 10-13.9-year age group and 50(28 girls, 22 boys) in the 14-18-year age group.

After the trial, the mean of all anthropometric measuresand cardiometabolic risk factors decreased significantly,and the mean HDL-C had a significant increase (Table 1).The percentage changes in variables studied according tothe age groups of participants are presented inFigure 1. Itshows that TG, LDL-C, DBP and WC had the highestdecrease in all age groups, with the most prominentchanges in the 14e18-year age group.

After the trial, the prevalence of MetS decreased from20.8% to 1.8%. The prevalence of cardiometabolic riskfactors before and after the trial decreased significantly inthose participants with and without MetS (Table 2).

Table 3presents the changes in cardiometabolic riskfactors by one SD decline in the BMI and WC according togender and age groups, and shows improvement of riskfactors by decline in both anthropometric measures.

4. Discussion

Our findings show that small reductions of excess weightthrough simple changes in lifestyle can be effective insignificant improvement of cardiometabolic risk factorsamong different age groups of obese children and adolescents. We suggest that motivating obese children and theirfamilies by encouraging healthy lifestyle through simpleoffice-based multidisciplinary counseling are effective, andcan be implemented as an integrated part of primaryhealthcare programs. Our simple and practical recommendations targeted the obesogenic habits of children andencouraged them to overcome these unhealthy habits. Ourprogram aimed to help obese children and adolescents tobecome more motivated by getting actively involved in theprocess of eating healthier and exercising regularly; insteadof making them feeling guilty and shameful for theirneglect of healthy lifestyles. As it is suggested that pleasureworks better than guilt as a motivator, and a weight-lossprogram should use the joy that comes from feeling andlooking better, not fear of dying,20we tried to supportchildren and families who needed encouragement to keepup a weight-loss program. Although it is well documentedthat lifestyle change through organized protocols includingsupervised physical activity of vigorous intensity9,21andresidential programs7,8are effective in reducing excess

weight and some cardiometabolic risk factors among obeseadolescents, limited experience exists on the efficacy ofuncomplicated programs with lower intensity. Although, asexpected, the current low-intensity trial achieved smallerchanges in cardiometabolic risk factors than did theabovementioned studies, its uncomplicated, comprehensive and motivating counseling style was effective, and wesuggest it is more feasible than residential and highintensity programs. Family-centered programs have beensuccessful in improving lifestyle behaviors of households,22as well as in reducing anthropometric and metabolicmeasures of obese children and adolescents.23In thecurrent trial, we have motivated children and adolescentsand in turn controlled their weight gain and cardiometabolic risk factors. The high compliance of participants and their families and the negligible drop-out rate ofthis trial is evidence for its practicability, and the favorable changes in cardiometabolic risk factors shows the efficacyof motivational counseling by physicians and nurses withoutneed for a structured program with collaboration ofdifferent specialists who are not easily reached in differentcommunity settings. A hospital-based, family-centeredintervention has been shown to reduce weight gain inoverweight children and adolescents,24and our findings areconsistent with this. Such experience is scarce fromdeveloping countries; our findings are confirmation of therole of health professionals in promoting preventivemeasures and encouraging positive lifestyle behaviors,as well as identifying and treating obesity-relatedcomorbidities.

Our findings about the improvement in cardiometabolicrisk factors, including the components of MetS, throughlow-intensity interventions are in agreement with someprevious randomized control trials of at least 8 weeks.

These studies showed that aerobic exercise training andhealthy diet are effective in lowering plasma concentrationof LDL-C and TG26-28and increasing HDL-C,28,29 as well asreducing SBP and DBP.26,30The better results in the 14-18-year age group than in other age groups might be becausecompared to younger age groups, notably those aged lessthan 10 years, they pay more attention to their body imageand might have better compliance for lifestyle change.Given that interventional programs have been effective inincreasing insulin sensitivity,9,29,31,32the beneficial effectsdocumented in the current study might be attributed toimprovement in insulin sensitivity. In addition, some factorssuch as decreased sympathetic nervous system activity,decreased extracellular fluid volume and normalization ofthe renineangiotensinealdosterone system are proposed asunderlying mechanisms of lowering blood pressure after calorie restriction and exercise.Our findings mightsuggest that low-intensity interventions for lifestyle modi-fication of obese children and adolescents can be beneficialfor decreasing insulin resistance even without reachingideal body weight.

In addition to its clinical implication on the favorablechanges in cardiometabolic risk factors, the simple officebased counseling used in the current study might haveimpact on public health programs for primordial/primaryprevention of chronic diseases.

Childhood obesity is largely underdiagnosed and undertreated; the role of the primary care providers in its timelyassessment and management is underscored.

A review of published articles confirmed the efficacy ofoffice-based promotion of physical activity for treatmentand prevention of childhood obesity.35Although a nonrandomized trial has shown that motivational interviewingby pediatricians and dietitians can be a promising officebased strategy for prevention and control of childhoodobesity,36the role of pediatricians in controlling theemerging epidemic of childhood obesity is generallyfocused on screening and prevention of childhood overweight and associated morbidities,37e39and less attentionis paid to their role in treatment options. Results of qualitative research in the USA showed that pediatricians followmany of the obesity prevention guidelines40; meanwhile inthe same community, 10e18-year-old youths reportedinfrequently receiving counseling on specific overweightprevention topics during routine primary care visits.

According to the Expert Committee on childhoodobesity, the use of patient-centered counseling techniquessuch as motivational interviewing for prevention of childhood obesity can be useful for prevention of childhoodobesity. Whereas for treatment, the recommendationspropose four stages of obesity care: the first is brief counseling that can be delivered in a healthcare office, andsubsequent stages require more time and resourcesaccording to the patient’s age and degree of excessweight.42MetS is not a single entity and consists of severaldistinct but interrelated entities43; healthy lifestyle may bethe core for prevention and control of these entities.

4.1. Study limitations

We acknowledge that this study was a nonrandomized trialwithout control, and various confounders might haveinfluenced the findings. However the large sample size,and inclusion of children and adolescents with diversesocio-demographic backgrounds, reduces the effect ofconfounders.

5. Conclusion

Our findings suggest that motivational office-based counseling can be effective in treatment of obesity and itsassociated cardiometabolic risk factors. Such an approachcan be implemented in the primary healthcare system,especially in low- and middle-income countries with limitedhuman and financial resources.

Increasing the delivery of obesity prevention andmanagement services requires a change in approach.Instead of focusing on disease and making sick childrenwell, we must focus on health promotion and spend moretime on counseling and preventive efforts. Apparently, therestoration of health is an approach superior to the treatment of disease and its accompanying symptoms, notably inthe pediatric age group. We suggest that intensifying theroles of nonphysician clinicians such as nurse practitionerscan help to increase the amount of time available for suchservices.

Acknowledgments

This study was funded as a thesis by Vice-Chancellery forResearch, Isfahan University of Medical Sciences, Isfahan,Iran.