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Международный эндокринологический журнал Том 19, №1, 2023

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Сімейна поведінкова терапія в лікуванні ожиріння в дітей шкільного віку

Сімейна поведінкова терапія в лікуванні ожиріння в дітей шкільного віку

Авторы: T.V. Sorokman, S.V. Sokolnyk, N.O. Popeluk
Bukovinian State Medical University, Chernivtsi, Ukraine

Рубрики: Эндокринология

Разделы: Клинические исследования

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Резюме

Актуальність. Ожиріння вражає 27–34 % дітей і вважається головною проблемою громадського здоров’я. Оскільки все більше дітей страждають від надмірної маси тіла, медичним працівникам необхідно шукати ефективні методи профілактики та лікування ожиріння. Мета: оцінити ефективність сімейної поведінкової терапії в лікуванні дітей із ожирінням. Матеріали та методи. Впродовж одного року під спостереженням перебувало 57 дітей віком 7–12 років з ожирінням, які були рандомізовані в дві групи: основну (інтервенційна) — 34 особи (I) та порівняння — 23 особи (II). Діти I групи включені в програму сімейного поведінкового лікування, що полягала в гіпокалорійному харчуванні, контролі за сімейним середовищем та дозованому контрольованому фізичному навантаженні. Ліпідний спектр крові вивчався за рівнем загального холестерину (ЗХС), тригліцеридів (ТГ), холестерину ліпопротеїнів низької (ХС ЛПНЩ) і високої щільності (ХС ЛПВЩ). Результати. У дітей з ожирінням як систолічний (САТ), так і діастолічний арте­ріальний тиск (ДАТ) був підвищений (становив у середньому 125,9 ± 0,9 мм рт.ст. i 66,9 ± 1,2 мм рт.ст. відповідно), також виявлено зростання концентрації ЗХС, ТГ, ХС ЛПНЩ. Через рік після проведення сімейної поведінкової терапії ІМТ у дітей з ожирінням знизився з 26,8 до 25,1 кг/м2, міжгрупові зміни САТ та ДАТ були статистично значущі (I група: до програми САТ становив 124,9 ± 0,8 мм рт.ст., після — 118,9 ± 0,9 мм рт.ст., р < 0,05; ДАТ — 65,7 ± 1,2 мм рт.ст. і 62,1 ± 1,0 мм рт.ст. відповідно, р < 0,05; II група: до програми САТ був 125,1 ± 0,7 мм рт.ст., після — 126,9 ± 0,8 мм рт.ст., р > 0,05; ДАТ — 66,6 ± 1,1 мм рт.ст. і 67,7 ± 1,2 мм рт.ст. відповідно, р > 0,05). Також відбулися достовірні зміни в ліпідному спектрі крові: рівень ЗХС знизився в 0,87 разa, ТГ — у 0,94 разa, при тенденції до зниження ХС ЛПНЩ та підвищення ХС ЛПВЩ. Висновки. Полікомпонентна сімейна поведінкова терапія є ефективною щодо зниження індексу маси тіла дітей з ожирінням. Отримані результати вказують на необхідність застосування запропонованої лікувальної програми в клінічній практиці.

Background. Obesity affects 27–34 % of children and is considered a major public health problem. As more and more children suffer from overweight, health professionals need to find effective methods of obesity prevention and treatment. The purpose was to evaluate the effectiveness of family behavioral therapy in the treatment of obese children. Materials and methods. For one year, 57 obese patients aged 7–12 years were under observation, they were randomly divided into 2 groups: a treatment group of 34 children (I) and a comparison group of 23 people (II). Group I children participated in the family behavioral treatment program, which included hypocaloric nutrition, control over the family environment, and dosed, controlled physical activity. The blood lipid spectrum was studied by the level of total cholesterol (TCh), triglycerides (TG), low-density lipoprotein cholesterol (LDL-Ch) and high-density lipoprotein cholesterol (HDL-Ch). Results. In obese children, both systolic (SBP) and diastolic blood pressure (DBP) were elevated (mean of 125.9 ± 0.9 mm Hg and 66.9 ± 1.2 mm Hg, respectively), an increase in the concentration of TCh, TG, and LDL-Ch was detected. One year after family behavioral therapy, body mass index in obese children decreased from 26.8 to 25.1 kg/m2, changes in SBP and DBP were statistically significant between groups (group I: SBP before was 124.9 ± 0.8 mm Hg, after — 118.9 ± 0.9 mm Hg, p < 0.05; DBP was 65.7 ± 1.2 mm Hg and 62.1 ± 1.0 mm Hg, respectively, p < 0.05; group II: SBP before the program was 125.1 ± 0.7 mm Hg, after — 126.9 ± 0.8 mm Hg, p > 0.05, DBP was 66.6 ± 1.1 mm Hg and 67.7 ± 1.2 mm Hg, respectively, p > 0.05), and there were also significant changes in blood lipids: the level of cholesterol decreased by 0.87 times, TG — by 0.94 times, with a tendency to LDL-Ch decrease and HDL-Ch increase. Conclusions. Multicomponent family behavioral therapy is effective in reducing the body mass index of obese children. The obtained results indicate the need to apply the proposed treatment program in clinical practice.


Ключевые слова

діти шкільного віку; ожиріння; індекс маси тіла; артеріальний тиск; ліпідний спектр; сімейна поведінкова терапія

school-aged children; obesity; body mass index; blood pressure; lipid spectrum; family behavioral treatment

doi: http://dx.doi.org/10.22141/2224-0721.19.1.2023.1238

Introduction

Pediatric obesity is a growing global epidemic that requires attention due to the burden it places on the health care system [1, 2]. Consumption of fatty foods and a diet with a high sugar content, lack of physical activity are considered the main causes of obesity among children and adolescents [3, 4].
Obesity affects 27–34 % of children and is considered a major public health problem. For the US pediatric health care system, costs were $179 per year higher for children with obesity compared to children with a normal body mass index (BMI) [5, 6]. Childhood obesity is associated with an increased risk of various diseases such as diabetes, cardiovascular disease, stroke, some types of cancer later in life, social problems and depression among adolescents [7, 8]. As more and more children suffer from overweight, health professionals need to find effective methods of obesity prevention and treatment. Over the past 30 years, childhood obesity has more than doubled in children and tripled in adolescents worldwide [9, 10].
Treatment of obesity involves changing the child’s diet and physical activity level. Depending on the state of health of the children, a multidisciplinary team should be involved in the treatment, which includes a family doctor, a nutritionist, and a psychologist. Where general recommendations are ineffective, specific dietary and physical activity plans must be developed.
Family-based behavioral treatment (FBT) is an evidence-based treatment for pediatric obesity. FBT has primarily been implemented in specialty clinics, with highly trained interventionists [11].
The purpose was to evaluate the effectiveness of family behavioral therapy in the treatment of children with obesity.

Materials and methods

For one year, 57 children aged 7–12 years with obesity were under observation, who were randomly divided into 2 groups: a treatment group of 34 people (I) and a comparison group of 23 people (II). Group I children were involved in the family behavioral treatment program, which included hypocaloric nutrition, control over the family environment, and dosed, controlled physical activity. The goal and interval of the behavior were discussed with the child and parents. A diet modification plan and a step-by-step list of necessary food items to exclude or include were prepared for them, and they were informed about the daily calorie requirement based on the recommended food composition tables. These tables were provided to each family so they could calculate their daily calorie intake. The children kept a diary of their behavior in order to monitor compliance with the recommended lifestyle changes. Parents monitored the diary and their child’s progress in achieving the new behavior. Methods of dosed physical activity were also prepared, in accordance with the wishes of the research participant, in particular, playing football, volleyball, swimming, brisk walking for 20 minutes 4 times a week. Control over physical activity was carried out by parents.
All patients included in the study were under the constant observation of physician and a specially trained nurse-bachelor, who visited patients once a month in order to observe the family environment, inspect the place where food is stored, determine the style of cooking and the characteristics of food that usually used in the family. During the visit, the behavior diary was also checked and gaps in the records were discussed. Potential methods of encouragement and punishment were discussed with parents and children during home visits.
Primary screening included a survey, anthropometry (height, weight, BMI calculation). Weight was measured without clothing and calibrated to the nearest 0.1 kg. Height was measured without shoes and calibrated to the nearest 0.1 cm. Obesity was diagnosed by BMI, which is equal to or higher than the 95th percentile. Weighing was carried out on a Body Fat Analyzer ВF-662W scale with determination of the percentage of fat mass. In addition, the 2007 IDF Consensus guidelines were used, according to which abdominal obesity is diagnosed in children aged 10–16 years with a waist circumference equal to or greater than the 90th percentile for age and sex. According to the results of anthropometric measurements, the children were divided into two groups: 30 people with abdominal obesity type (AOT) and 27 people with uniform obesity type (UOT).
Blood pressure was measured with a standard Riva-Rocci sphygmomanometer with an appropriately sized cuff, and the last two measurements were averaged. The blood lipid spectrum was studied by the level of total cholesterol (TCh), triglycerides (TG), low-density lipoprotein cholesterol (LDL-Ch) and high-density lipoprotein cholesterol (HDL-Ch) by the photometric method on a general purpose photometer Cormay Multi (Poland).
Exclusion criteria were the presence of kidney, liver and/or cardiovascular diseases; metabolic and/or endocrine disorders; genetic syndromes; chronic allergy, acute infectious or inflammatory diseases during the last 3 months preceding the study. None of the participants was taking medication.
Statistical data analysis was performed using the Statistica 10.0 application program package. The results are presented in the form of mean value and standard deviation (M ± σ). The nature of the distribution was determined using the Kolmogorov-Smirnov criterion. The Student’s t-test was used to compare values with their normal distribution. Differences were considered statistically significant at p < 0.05.
Patient studies were conducted in accordance with the provisions of the Helsinki Declaration of 1975, revised and supplemented in 2002, and the directives of the National Research Ethics Committees (Bioethics commission of the Bukovinian State Medical University, protocol 3 11/18/2022). During the tests, informed consent was obtained from all participants and all measures were taken to ensure the anonymity of the participants.

Results

All patients were divided by age and gender (Table 1): from 7 to 9 years, 17 people, of which 7 were boys and 10 were girls; from 10 to 12 years old (40 people, including 19 boys and 21 girls). In children with AOT, secondary hypothalamic form (73.3 %) and obesity degree II–III were significantly more often registered. The primary exogenous constitutional form of obesity (62.9 %) and obesity degree I–II were found significantly more often in the group of children with UOT.
Measurement of blood pressure in obese children showed an increase in both systolic (mean systolic blood pressure 125.9 ± 0.9 mm Hg) and diastolic (mean diastolic blood pressure 66.9 ± 1.2 mm Hg).
Indicators of the blood lipid spectrum (TCh, LDL-Ch, TG) were higher in children with obesity (Table 2).
The initial characteristics of the sample of obese children of I and II observation groups are presented in Table 3.
Changes in height and body weight in children of both groups during the observation period are presented in Table 4.
One year after family behavioral therapy, there were significant changes in the lipid spectrum of the blood in obese children (Table 5). Thus, the level of TCh decreased by 0.87 times, TG — by 0.94 times, with a tendency to decrease LDL-Ch and increase HDL-Ch.
Intergroup changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were statistically significant (group I: SBP before the program was 124.9 ± 0.8 mm Hg, after — 118.9 ± 0.9 mm Hg, p < 0.05; DBP 65.7 ± 1.2 mm Hg, after — 62.1 ± 1.0 mm Hg, p < 0.05; II group: before the program SBP 125.1 ± 0.7 mm Hg, after — 126.9 ± 0.8 mm Hg, p > 0.05, DBP 66.6 ± 1.1 mm Hg, after — 67.7 ± 1.2 mm Hg, p > 0.05).
Therefore, intervention in the lifestyle of children with obesity leads to positive and stable results.

Discussion

Childhood obesity remains an important public health problem and prevention programs should be a priority to reduce the prevalence of obesity. Most randomized controlled trials report benefits of lifestyle interventions in overweight/obese children [12–15].
A number of identified strategies used to treat childhood obesity range from lifestyle approaches, pharmacotherapy to surgery [16, 17]. Almost all studies indicate that dietary treatment of children and adolescents with obesity should be aimed at ensuring adequate growth by reducing excessive fat accumulation, avoiding loss of lean body mass, improving well-being and self-esteem, and preventing cyclic weight regain [18–20]. There is evidence that dietary interventions are more effective in achieving weight loss when combined with other strategies such as increased physical activity and/or psychological interventions to promote behavior change [21]. Integrated interventions that combine diet, physical activity, and control of the family environment have been found to be significantly correlated with a reduction in BMI [22].
Our findings correlate with evidence from previous meta-analyses suggesting that multiple lifestyle changes may be beneficial in controlling children’s weight in the short- and long-term [23, 24]. The use of dosed exercise may reduce BMI but may not improve metabolic outcomes, which are improved only when exercise is combined with diet and a supportive family environment. Prevailing guidelines suggest that school children should receive at least 60 minutes of moderate physical activity each day [25]. In our study, a low-calorie diet, 20 minutes of exercise 4 times a week, and control of the family environment appeared to have excellent results, especially in lowering TG and TCh. High-intensity physical activity is difficult to achieve in the family, it can only be achieved in a sports section or a sports camp.
Our studies indicate that the effectiveness of childhood obesity treatment is more profound when lifestyle intervention includes several components, namely hypocaloric nutrition, control of the family environment, and dosed controlled exercise.
No side effects were observed during the treatment. Obese children in both groups had a linear increase in height similar to that of normal-weight children. No participant in the treatment program dropped out due to any problems.

Conclusions

Multicomponent family behavioral therapy is effective in reducing the body mass index of obese children. The obtained results indicate the need to apply the proposed treatment program in clinical practice.
 
Received 06.12.2022
Revised 10.01.2023
Accepted 24.01.2023

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