Obesity management should be initiated early during
childhood. We aimed to assess the effects and factors influencing an
intervention combining physical activity and Family-Based Behavioral Treatment (FBBT)
in group setting, on Body Mass Index (BMI) and psychological co-morbidities in
3 to 7 years old children with obesity. This is a clinical trial pilot study
including 17 overweight or obese children, aged 3 to 7 years old, and their
parents. The low-intensity intervention included 9 group sessions based on the
FBBT approach spread over 12 months. For the 13 subjects who completed the
study (76.5%), the BMI z-score was stable during the first 6 months (delta BMI
z-score: 0.06±0.3), but increased at one year
(0.23±0.4). At 12 months, it was influenced by the
psychological states of the child and father (child emotional problems:
r=0.606, p=0.048; father depression: r=0.821, p=0.012; father anxiety: r=0.723,
p=0.043). Conclusions: This pilot study suggests that there is a relationship
between BMI z-score in young children and children behavior, father support,
and psychological disorders. This is an interesting issue, with novel results.
Keywords: Children; Family; Obesity; Psychological States; Weight Management Program
Abbreviations:
FBBT : Family-Based
Behavioral Treatment
BMI : Body Mass
Index
SDQ : Strengths
and Difficulties Questionnaire
BDI : Beck
Depression Inventory
BAI : Beck Anxiety Inventory
What Is Known:
·
Family patterns
of eating behaviors have a role in the child’s weight.
· There is a higher frequency of depressive disorders in parents of obese children and adolescents compared with parents of non-obese children.
What Is New:
·
The father’s support
and psychological state has a crucial role to maintain long term participation
to a weight management program.
1. Introduction
The Family-Based Behavioral Treatment (FBBT) was developed to
modify the shared family environment, and to provide role models and support
for child behavior changes [1].
We aimed to assess the effects of a low-intensity intervention
combining physical activity and FBBT in group setting, on Body Mass Index (BMI)
and psychological co-morbidities in 3 to 7 years old children with obesity and
their parents. We also aimed to investigate factors influencing treatment
adherence and success.
2. Methods
This was a clinical trial pilot study including 13 overweight or
obese children, aged 3 to 7 years old, and their parents.
The « Ethics Commission for
Research on the Human Being » (CEREH) (n°de ref. CER :13-172)
ethics committee approved this study and a written informed consent was
obtained from parents.
The intervention included 9 one-hour group sessions spread over
12 months. Parents and children sessions were held separately. The parents’
sessions were co-led by two health care professionals: one dietitian and one
psychologist. Children sessions were directed by a psychomotor therapist, a
pediatrician and a nurse.
We assessed anthropometrics variables at baseline, after 6 and
12 months using standardized methods. The French version of the Strengths and
Difficulties Questionnaire (SDQ)[2], the French versions of the Beck Depression
Inventory (BDI) [3] and the Beck Anxiety Inventory
(BAI) [4] were filled by parents at baseline and after 12 months.
Statistical analyses were performed using the SPSS software 18.0
(Chicago, IL). Pearson coefficient correlation, paired t-test,
independent Student’s t-test and Chi-2 were used when
appropriate.
BMI z-score was considered stable if the change was ±0.1. Differences were
considered significant if p < 0.05.
3. Results
Characteristics of the subjects and SDQ questionnaire results
are presented in (Table 1). Results of the BDI and the BAI are presented
in (Table 2). The BMI z-score was stable at 6 months, but there was
a trend towards an increase at 12 months (Table 1).
Compared to the SDQ normative data, only 30% of children were
considered as normal for total difficulty scoring (30% borderline and 40%
abnormal) the father’s depression and anxiety levels (BDI and BAI total
scores) were positively correlated with the BMI z-score change at 6 months
(BDI: r=0.821, p=0.012; BAI: r=0.723, p=0.043) and at 12 months (BDI: r=0.793,
p=0.019; BAI: r=0.931, p=0.001). Moreover, maternal and paternal questionnaires
completion rates at 12 months were significantly inversely correlated to the
BMI z-score change at 12 months (mothers: r=-0.608, p=0.027; fathers: r=-0.698,
p=0.008).
The child’s emotional problem score was positively correlated at
12 months with BMI z-score change (r=0.606, p=0.048). There was a significant
difference between emotionally normal and abnormal subjects (Delta BMI z-score
-0.19±0.2 kg.m-2 vs. 0.37±0.4 kg.m-2; p=0.039).
Baseline subjects’ characteristics, questionnaires result, and
evolution were similar between the high (>75% of sessions) and low
participation rate groups (Table 1). However, the paternal questionnaire
completion rate at baseline tended to be greater in the high participation rate
group (High: 6/7 vs. Low: 2/6; p=0.053).
4. Discussion
Childhood obesity is a major public health challenge as its
prevalence is increasing worldwide and it is tracking into adulthood, with a
4-fold increased risk for young children aged 2 to-5 years [5]. This
pilot study showed that the BMI z-score was stable during the first 6 months of
intervention, but increased after one year, which is in accordance with a
systematic review on the same age group [6]. However, the last
Cochrane review showed better results but the overall quality of the trials was
low [7]. These findings highlight the difficulty for families to
sustain efforts over a long period of time.
Surprisingly, the weight outcome was not influenced by the
participation rate but rather by the global implication of the
family [8] and the psychological states of the child and their
father. Indeed, BMI z-score changes were positive when the father was suffering
from depressive disorder, and/or when the child was suffering of emotional
problems. Paternal depression has been shown to have an impact on adverse
emotional and behavioral outcomes in children aged 3 to 5 years [9].
Furthermore, we observed that the participation rate was
dependent of the father’s support, assessed indirectly through their
willingness to complete the questionnaires. This finding suggests that an
active implication of the father in the therapeutic process may help the mother
and child to sustain their efforts. However, it has to be confirmed in
randomized controlled trials comprising the father’s participation. A recent
review investigated the factors influencing the drop-out rate but surprisingly
no study investigated the role of the father [10].
In conclusion, despite a small sample size, this study suggests
that it feasible to implement a low-intensity physical activity and FBBT for
the weight management of young children, however it is very difficult to
reduced or maintain the BMI z-score over time. This study highlights the influence
of the child’s behavior and of the father’s support and psychological states
for the participation in a weight management program.
5. Compliance with Ethical Standards
5.1. Conflict of interest: The authors have no
conflicts of interest to declare.
5.2. Funding:
This study was supported financially by the Geneva Pediatric Network, the Hans
Wilsdorf foundation and the University Hospitals of Geneva. The work was
independent of the funding.
5.3. Informed consent :
The Ethics Commission for Research on the Human Being (CEREH) (n°de ref. CER :13-172)
ethics committee approved this study and a written informed consent was
obtained from parents.
6. Acknowledgements
We thank the subjects for volunteering for the study and the
Department of the Public Instruction of the Geneva state for the free
utilization of the premises. We thank the “Quarantezéro tennis academy” and
Murielle Thurnherr, psychomotor therapist, for their participation.
7. Authors’ contribution
MM, LP, and MBM conceived and carried out experiments, VD, NFL,
AR and JSL conceived experiments. AM conceived experiments, analyzed data and
wrote the manuscript. XM carried out experiments. All authors were involved in
writing the paper and had final approval of the submitted and published
versions.
|
All N=13 |
Low attendance rate (<75%) N=6 |
High attendance rate (>75%) N=7 |
p |
|
Mean ± SD |
Mean ± SD |
Mean ± SD |
|
Mean participation rate, % |
75.2 ± 20.9 |
57.4 ± 13.0 |
90.5 ± 11.9 |
0.001 |
Characteristics |
||||
Age, years |
6.0 ± 1.1 |
6.2 ± 1.4 |
5.9 ± 1.0 |
NS |
BMI z-score at baseline, kg.m-2 |
2.8 ± 0.9 |
2.9 ± 1.0 |
2.8 ± 0.8 |
NS |
Delta BMI zs at 6 months, kg.m-2 |
0.06 ± 0.3 |
0.03 ± 0.2 |
0.09 ± 0.3 |
NS |
Delta BMI zs at 12 months, kg.m-2 |
0.23 ± 0.4 |
0.21 ± 0.4 |
0.25 ± 0.5 |
NS |
Psychological factors |
||||
SDQ questionnaire |
|
|
|
|
Pro-social behavior |
7.6 ± 3.9 |
9.0 ± 1.2 |
6.7 ± 2.4 |
NS |
Emotional problems |
3.5 ± 2.2 |
4.0 ± 2.9 |
3.1 ± 1.8 |
NS |
Conduct problems |
2.9 ± 2.2 |
2.8 ± 2.2 |
3.0 ± 2.4 |
NS |
Hyperactivity/inattention |
2.9 ± 1.7 |
3.3 ± 2.1 |
2.7 ± 1.6 |
NS |
Peer relationship problems |
1.9 ± 1.5 |
1.7 ± 1.2 |
2.0 ± 1.6 |
NS |
Total difficulty score |
11.6 ± 3.9 |
13.3 ± 0.6 |
10.9 ± 4.6 |
NS |
Results are presented as mean and standard deviation Abbreviations: BMI: body mass index; NS: non-significant; SDQ: Strengths and Difficulties Questionnaire |
Table 1: Characteristics of subjects who complete the study (per protocol analyses).
|
Mothers N=13 |
Fathers N=13 |
|
N (%) |
N (%) |
BDI : |
||
No depression |
5/12 (41.7) |
5/8 (62.5) |
Mild depression |
1/12 (8.3) |
1/8 (12.5) |
Moderate depression |
6/12 (50) |
1/8 (12.5) |
Severe depression |
0 |
1/8 (12.5) |
Missing questionnaire |
1/13 (7.7) |
5/13 (38.5) |
BAI: |
||
No to mild anxiety |
10/12 (83.3) |
5/5 (100) |
Moderate anxiety |
2/12 (16.7) |
0 |
Missing questionnaire |
1/13 (7.7) |
8/13 (61.5) |
Mixed: |
||
Anxio-depressive |
2 (16.7) |
0 |
Abbreviations: BDI: Beck Depression Inventory; BAI: Beck anxiety Inventory |
Table 2: Results of BDI and BAI Questionnaires at baseline (per protocol analyses).
- Epstein LH, Valoski A, Koeske R, Wing RR (1986) Family-based behavioral weight control in obese young children. J Am Diet Assoc 86: 481-484.
- Goodman R
(1997) The Strengths and Difficulties Questionnaire: a research note. J Child
Psychol Psychiatry 38: 581-586.
- Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4: 561-571.
- Beck AT, Epstein N, Brown G, Steer RA (1988) An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 56: 893-897.
- Freedman DS, Khan LK, Serdula MK, Dietz WH, Srinivasan SR, et al. (2005) The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study. Pediatrics 115: 22-27.
- Bond M, Wyatt K, Lloyd J, Taylor R (2011) Systematic review of the effectiveness of weight management schemes for the under fives. Obes Rev 12: 242-253.
- Colquitt JL,
Loveman E, O'Malley C, Azevedo LB, Mead E, et al. (2016) Diet, physical
activity, and behavioural interventions for the treatment of overweight or
obesity in preschool children up to the age of 6 years. Cochrane Database Syst
Rev 3: CD012105.
- Bracale R,
Milani Marin LE, Russo V, Zavarrone E, Ferrara E, et al. (2015) Family
lifestyle and childhood obesity in an urban city of Northern Italy. Eat Weight
Disord 20: 363-370.
- Ramchandani P, Stein A, Evans J, O'Connor TG (2005) Paternal depression in the postnatal period and child development: a prospective population study. Lancet 365: 2201-2205
- Skelton JA, Beech BM (2011) Attrition in paediatric weight management: a review of the literature and new directions. Obes Rev 12: e273-e281.