Experience with family based intervention against overweight Carl-Erik Flodmark

Childhood Obesity UnitDept of Pediatrics in Malmö, Sweden16th Nordic Congress of General PracticeCopenhagen 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 Med 25, 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 Med 166, 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 Suppl 94, 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

BackgroundBackgroundChildhood Obesity Unit Childhood Obesity Unit

The board for health and hospital care started 2001 The board for health and hospital care started 2001 a project of three years for establishing a knowledge a project of three years for establishing a knowledge and treatment centre for obese children in the and treatment centre for obese children in the Region Skåne. 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 Co-operation within a team is necessary to offer a treatment specially designed for the familytreatment specially designed for the family

Nurse

Pediatrician

The childand the family

Dietitian

Psychologist

Sports trainer

Information

assistant

GoalSolution

Multidisciplinary team Multidisciplinary team

Treatment modelsSOFT

Standardised Obesity Family TherapySingle family treatment:

First visit includes– Full team

– Investigation– Evaluation

– Goals for this family

Follow-up is done using smaller teams

 

Flodmark, CE. Pediatrics (1993) 91:880-884Nowicka, 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

XX

Baseline data

Mean age 10.9Mean BMI 31.7Mean BMI SDS 3.67

82% BMI z-scores >3.0 (extremely obese)

52% BMI z-scores 3.5 (morbidly obese).

ResultsBMI z-score changes

6 8 10 12 14 16 18

23

45

Age

BM

I z-s

co

re

GirlsBoys

International Journal of Pediatric Obesity (2007) 2:211-217

Intervention resulted in a mean decrease in BMI z-score of 0.12 (p=0.0001).

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

Screening Start End

**

*

**

* Mann Whitney U test

6 sessionsduring 18months

Follow-up of 87 obese children

24

25

26

27

28

29

0 1 2 3 4

Years

%O

verw

eig

ht

Family therapy Conventional treatment Control

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 contFollow-up of 61 obese children

010203040506070

0 20 40 60 80 100 120

Months

%O

verw

eig

ht

Child+parent Child Control

*

*

*

*

* ANOVA Sign

Eight weeklysessions,six monthlymeetings

6-12 year olds

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

ANOVA Time effect sign, but group effect NS

12 sessions,monthly follow-upfor one year

Follow-up of 109 obese children

30

40

50

60

0 1 2 3 4 5

Years

%O

verw

eig

ht

Group Individual Camp Advice 1 session

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.Nowicka P. International Journal of International Journal of Pediatric Obesity (2008) 3:141-147Pediatric Obesity (2008) 3:141-147

BMI SDS (-0. 09, p=0.039) decreased in all children ≤ BMI z-scores 3.5, as compared with the control group.

ResultsThe follow-up one year after study start

Family Weight School Cost 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 Treatment 3.8 visits

Family Weight School 3.4 visits

Cost of treatment

Single Family Treatment 3 000 €  per family

Family Weight School 1 300 €  per family

A professional conversation

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

More information

SPOC 9-10 July 2010

Scandinavian Pediatric Obesity ConferenceSPOC 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

Thank you!