June 10, 2007
Family Intervention and Therapy for Overweight and Obese Kids
By Lake, Karen
Follow the progress of the pilot FIT-OK project in Peterborough as they attempt to tackle the growing problem of childhood obesity Background
Childhood obesity is associated with adverse health outcomes, both physical and psychosocial. Studies have associated child obesity with cardiovascular risk factors,1,2,3 as well as insulin resistance syndrome.4 Obese adolescents are more likely to become obese adults.5,6,7,8 Due to the increasing number of obese and overweight children,9,10 tackling child obesity is a public health priority and is now a Public Service Agreement (PSA) target.11
This paper outlines a pilot project undertaken in Peterborough, to treat obese children.
In 2004, a multi-agency 'Child Obesity Action Group' was set up. The group's remit was to devise a strategy to help tackle child obesity. The strategy was to include three main areas: prevention, monitoring and treatment of child obesity. In relation to treatment, the group identified a lack of specialist services to manage obese children.
A review of the literature highlighted that targeting parents and children together, and involving one parent in a programme, is effective in treating obese and overweight children.12,13
With this in mind, a proposal was written for a specialist team and programme, named FIT-OK (family intervention and therapy for overweight and obese kids). The project lead applied and won an award for Pounds 15,000 from the Queens Nursing Institute (QNI). The FIT-OK pilot was launched in December 2005 and finished in October 2006.
Aims and objectives of FIT-OK
The project primarily aimed to promote healthier lifestyles to families with children who are obese and overweight by: increasing the family's awareness of obesity and boosting the child's self esteem.
The FIT-OK team
The team, headed by a project lead, consisted of four FIT-OK 'trainers', two health visitors, one school nurse and one dietitian technician. Specialist team members included: one paediatric dietitian, two sports specialists and one children's learning disabilities support worker. Advisory specialists were available if needed, including a consultant dietitican for obesity and a paediatrician.
Once a family was accepted on to the project, a FIT-OK 'trainer' undertook an initial assessment that included recording a history of the family lifestyle and food intake, the child's and parents' expectations, and the child's level of self esteem and baseline anthropometric measurements. The child and parent then attended the local specialist children's gym at Arthur Mellow Village College (AMVC) for their fitness test.
The FIT-OK team devised goals like healthy eating and physical activities, which were agreed with the family. The trainer's role was to motivate and support the family in reaching their weekly goals, with the child and participating parent attending the gym once or twice a week. The physical activity plan was designed to be sustainable and fit in with family life. Examples included walking the dog for 15 minutes a day and walking to and from school.
In December 2005,17 children who met the following criteria were accepted on to the project:
* Aged 4-16 years old
* 91st or 98th BMI centile14
* One parent willing to participate
* Family must be willing to change.
Children were accepted on to the project as they were referred between December 2005 and May 2006.
Of the 17 children originally accepted on to the project, 76% (n=13) were referred by professionals and 23% (n=4) were self referrals via parents. In the first few weeks, one child withdrew from the project and another dropped out after two months, leaving 15 children. The mean BMI z score at baseline was 3.1 (SDS ranged 2.2 - 4.7).
The majority of the children were white British, with one child from a white and Afro-Caribbean ethnic background. The mean age of the children on the project was 12.4 years old, and their weight ranged from 58kg up to 177kg. Five children had low self-esteem at their baseline measurement. Few children took part in any physical activity and none of the children ate the recommended five a day fruit and vegetables.
Health and co-morbidities
Several children had co-morbidities. This included: slipped capital femoral epiphysis, joint pains, exacerbation of asthma, hypothyroidism, learning disabilities, dyspraxia and autistic disorder.
Children's measurements were taken at baseline O, three and six months. These included:
* BMI centile (age and gender specific)
* Waist circumference
* Arm and thigh circumference
* Fitness test
* Fruit and vegetable intake
To minimise intra- and inter-observer bias, the same trainer measured the same child using the same technique and equipment.
The fitness test was multi-staged, in which the child had to run 20 metre 'shuttle runs' in time with an audio 'bleep', until the bleeps got too quick for the child.
This test was used to estimate the maximum endurance of the child and to test their aerobic capacity. At the baseline fitness test, 86% (n=13 out of 15) children, were classified in the 'very poor' category, one child scored 'poor' and one child did not attend.
Fifteen children completed three months and of those, 13 completed six months. From the 15 children, 60% (n=9) had slightly decreased their BMI z score. These children remained on or above the 98th centile (obese category). Weight losses were relatively small, the greatest weight loss being 5kg. Overall, the children did make changes to their lifestyle and continued to attend the gym regularly.
40% (n=6) slightly increased their BMI z score. Out of those children who gained weight, three children had learning disabilities and one child had hypothyroidism. The children with learning disabilities did attend the gym and work reasonably hard. The other remaining two children had no medical problems but they did have a lower attendance at the gym.
At final measurements, 84% (n=11) out of 13 increased their self- esteem. One child dropped out and did not repeat the questionnaire, one child remained the same and one child had lower self-esteem; this same child also gained weight.
Some children were unable to complete the Rosenberg questionnaire.15 To address this, the team designed a pictorial questionnaire, asking the children to indicate which 'face' represented how they felt today and how they felt about their bodies. Children ticked a 'happier' face at the end of the project.
Fruit and vegetable intake/physical activity
Children were asked to complete a three-day food diary at baseline. On the basis of this, the paediatric dietitian provided a dietary plan. A limitation of food diaries, however, was the potential under-reporting of food intake.16 In the final parent/ child survey, 80% (n=12) out of 15, reported that they had increased their fruit and vegetable consumption. It was difficult to ascertain by how much, as diaries were sometimes incomplete. 80% (n=12) out of 15 children reported that they were 'more active' in their lifestyles.
Since the project ended, two families have continued to regularly use the children's gym. From the children that repeated their fitness test, 87.5% (n=7) out of 8 improved their fitness on average by 33%. There were seven children who did not attend for their final fitness test.
69% (n=9 out of 13) children had decreased thigh circumference by an average of 3.6cm. 15% (n=2) increased by 2.9cm. Two children stayed the same and two did not repeat measurements.
46% (n=6 out of 13) had decreased arm circumference by an average 2.7cm, and 46% (n=6) increased by 1.8cm; one child stayed the same.
Waist circumference is a useful marker for central body fat accumulation. Waist circumference is linked to an increased risk of metabolic complications." Measurements were undertaken using the umbilicus as a marker," as this was easier with the more overweight children. 53% (n=7) children decreased their waist by an average of 2.4cm. 46% (n=6) increased by an average of 3.5cm. There were two children who did not have repeat measurements.
Qualitative data: what the parents say
Over half the parents changed their own lifestyle and acted as role models to their child. Some parents had not attended a gym before and really enjoyed it.
Most parents said they felt better, and one father said: ? can switch off from work'.
Taking part in the project influenced other areas of families' lives and even changed parents' outlook. In one case, a mother reduced her smoking from 60 to 10 cigarettes a day. She admitted she had a long way to go but had made a start.
What the children say
At the end of the project, children reported positive comments about going to the gym.
I don't get so puffed out.[boy aged 13]
I can run about more with my friends, [boy aged 12]
I feel better, [girl aged 12]
* 60% (n=9) decreased their BMI z score
* 40% (n=6) increased their BMI z score
* 80% (n=12) increased fruit and vegetable intake
* 80% (n=12) increased physical activity
* 86% (n=13 out of 15) scored very poor on their baseline fitness test, one child scored poor, one child did not attend the baseline test
* 87.5% (n=7 out of 8) who attended a repeat fitness test, and improved their fitness level by 33%. One child decreased and seven did not attend
* 84% (n=11 ) increased self esteem, two did not repeat the test, one chiayed the same and one child reported lower self-esteem. Scope and limitations
The pilot only included a small number of children over a short period of time. Children from ethnic minority groups were also under- represented. Data such as the food diaries were a self-reported measure and therefore contained potential bias: families might over or under-report.
The wide inclusion criteria proved to be both a strength and weakness. It meant that most children could be included. Children with complex needs and medical problems were accepted. However, these children seemed least successful in terms of reduction of their BMI centile. This probably affected the overall results.
Plans for the future
FIT-OK was the first family-based project for obese children in Peterborough. We are hoping to mainstream the project; discussions are underway with all the agencies. We would recommend some minor amendments, such as reviewing the criteria for acceptance, and whether children with severe obesity and complex needs may not be suitable; adopting a cohort approach, by having several families start at the same time. This would provide more opportunities for peer support. It would also lend itself to delivering group nutritional sessions throughout the programme in addition to the individual advice.
Tips for setting up similar schemes
This project could be adapted to other areas. The success of the project is due to the multi-agency team, particularly sports trainers and dietitians. Although we used a specialist children's gym, any sports hall or community venue could be used to set up a circuit class or other activities. The time of the session is important, as it needs to be after school and work, when both parents and children can attend. Team members need to be flexible in their working hours.
Team members collecting the Queen's Nursing Institute award, at the Cafe Royal, London, June 2006. Christine Hancock, third from right, presented the award
Steven. aged 11 years old, using the equipment in the gym
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Principal public health practitioner, Project lead FIT-OK
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