Experience with family based intervention against overweight Carl-Erik Flodmark Childhood Obesity Unit Dept of Pediatrics in Malmö, Sweden 16th Nordic Congress of General Practice Copenhagen 15th May 2009
The problems • Childhood obesity is increasing • The first step • Nutrition • Epidemiology: Bogalusa study: Total consumption of low-quality foods were positively associated with overweight status • Nicklas TA, Yang SJ, Baranowski T, Zakeri I & Berenson G (2003) Eating patterns and obesity in children. The Bogalusa Heart Study. Am J Prev Med25, 9-16 • Treatment: Calori intake more important than “fashion diets” • Nordmann AJ, Nordmann A, Briel M, Keller U, Yancy WS, Jr., Brehm BJ & Bucher HC (2006) Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med166, 285-93
The problems, cont. • The first step cont • Nutrition cont • In children there is no conclusive evidence regarding diets using low glycemic index or high-protein diets although reduction of soft-drinks seems to be efficient in prevention • Nowicka P (2005) Dietitians and exercise professionals in a childhood obesity treatment team. Acta Paediatr Suppl94, 23-9 • Physical acitivity • Systematic review of RCTs of physical activity treatment showed that an aerobic exercise prescription of 155-180 min/weeks at moderate-to-high intensity is effective for reducing body fat • Atlantis E, Barnes EH & Singh MA (2006) Efficacy of exercise for treating overweight in children and adolescents: a systematic review. Int J Obes (Lond)30, 1027-40
The problems, cont • The second step • Change of lifestyle • Professional conversation • Drugs • No licensed drugs in Europe • Not recommended • Surgery • No controlled trials • Not recommended • Prevention • Flodmark CE, Marcus C & Britton M (2006) Interventions to prevent obesity in children and adolescents: a systematic literature review. Int J Obes (Lond)30, 579-89.
Family based interventions • Seeing a family – group encounter • Interacting with a family – socio-environmental therapy • Treating a family • Behavioural therapy • Cognitive behavoural therapy • Family therapy
The reasons for this model • Behavioral therapy • Using behavioral performance based procedures to induce changes in behavior (re-learning) • Cognitive behavioral therapy • Using behavioral performance based procedures and cognitive interventions to produce changes in thinking, feeling and behavior
Psychological models cont • Family (systems) therapy • Using the encounter with a family to improve the members health by observing and analyzing interactions between family members but also with the therapists and improving the family’s ability to use their own resources • Group therapy • Review • Flodmark CE. Childhood Obesity. • Clinical Child Psychology and Psychiatry 1997;2: 283-295
Background Childhood Obesity Unit The board for health and hospital care started 2001 a project of three years for establishing a knowledge and treatment centre for obese children in the Region Skåne.
Childhood obesity unit Regional centre in 2004 A regional assignment for coordinating actions against childhood obesity by: • Informing about the disease childhood obesity and its health consequences • Establishing a dialogue with child health care, school health care and other present of future collaborating bodies. • Making this evidence based therapy based on family therapy available in the Region Skåne • Treating children with overweight including obesity
Multi-disciplinary approach • Medical (pediatric) • Nutrition • Physical activity • Psychological/social • Co-operation within a team is necessary to offer a treatment specially designed for the family
Multidisciplinary team Pediatrician Dietitian Goal Solution The child and the family Nurse Sports trainer Information assistant Psychologist
Treatment models SOFT Standardised Obesity Family Therapy Single family treatment: First visit includes – Full team – Investigation – Evaluation – Goals for this family Follow-up is done using smaller teams Flodmark, CE. Pediatrics (1993) 91:880-884 Nowicka, P. International Journal of Pediatric Obesity (2007) 2:211-217
Results • Eighty-one percent of the children and their parents participated in the follow-up. • Eleven children were treated for 6-12 months, and 33 for more than 12 months. • Families received 3.8 family therapy sessions. International Journal of Pediatric Obesity (2007) 2:211-217
Baseline dataMean age 10.9Mean BMI 31.7Mean BMI SDS 3.67 X 82% BMI z-scores >3.0 (extremely obese) 52% BMI z-scores 3.5 (morbidly obese).
ResultsBMI z-score changes • Intervention resulted in a mean decrease in BMI z-score of 0.12 (p=0.0001). International Journal of Pediatric Obesity (2007) 2:211-217
Family therapy • Ref. • Flodmark CE et al Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy • Pediatrics 1993;91:880-884 • Background • Tomm K: Interventive interviewing. Part III. Intending to ask linear, circular, strategic and reflexive questions? • Fam Process 1988;27, 1-45
Family therapy: BMI changes * 6 sessions during 18 months * * * * Screening Start End * Mann Whitney U test
Reflexions • Non-blaming approach showing respect (requires training) • Realistic goals (biological knowledge) • Small steps • Age adjusted strategies (requires understanding of psychological development)
Behavioural therapy • Ref. • Epstein L. H., Valoski A., Wing R. R. & McCurley J. Ten-year follow-up of behavioral, family-based treatment for obese children. • Jama 1990;264:2519-2523. • Background • Stuart R. B. Behavioral control of overeating. • Behav Res Ther 1967;5:357-365.
Behavioral Therapy cont * * Eight weekly sessions, six monthly meetings * * 6-12 year olds * ANOVA Sign
Cognitive behavior therapy • Ref. • Braet C. & Van Winckel M. Long-term follow-up of a cognitive behavioral treatment program for obese childr. • Behavior Therapy 2000;31:55-74. • Braet C., Van Winckel M. & Van Leeuwen K. Follow-up results of different treatment programs for obese children. • Acta Paediatr 1997;86:397-402
Cognitive behaviour therapy 12 sessions, monthly follow-up for one year ANOVA Time effect sign, but group effect NS
Future possibilities • Surgery – Not yet • Drugs – Not yet • Pedagogical and conversational treatments combined • Family weight school
Family weight school • Multiple family treatment • Education and conversational treatment for the teenagers 12-19 years of age and the family • 72 families were treated for one year • Evaluation regarding BMI, quality of life, diet and physical activity Nowicka P. International Journal of Pediatric Obesity (2008) 3:141-147
ResultsThe follow-up one year after study start • BMI SDS (-0. 09, p=0.039) decreased in all children ≤ BMI z-scores 3.5, as compared with the control group.
Family Weight SchoolCost of treatment • Intensity of treatment Braet C et al (Belgium) 30 visits per patient per year Epstein L et al (USA) 14 visits Single Family Treatment3.8 visits Family Weight School 3.4 visits • Cost of treatment Single Family Treatment3 000 € per family Family Weight School1 300 € per family
How do you do it? Is it effective? Is it cost-effective? Is it safe? How to start? Use psychological based treatments Better long-term results than in adults The method chosen might be important No indication of increased eating disorders Karl Tomm Systemic interviewing Fam Process 1988;27, 1-45 A professional conversation
More information SPOC 9-10 July 2010 Scandinavian Pediatric Obesity Conference SPOC official satellite of ICO Stockholm 2010, Sweden www.childhoodobesity.info The web page for Childhood Obesity Unit Region Skåne (publicerat=publication list): www.bravikt.info