A Multi - Disciplinary Therapy Program for Morbidly Obese Children and Teenagers : Results After 7 Months

Multi-Disciplinary Therapy Program for Morbidly Obese Children & Teenagers
Clinical Article
A Multi-Disciplinary Therapy Program for Morbidly
Obese Children and Teenagers: Results After 7 Months
Sabine Dietrich, MD; Kurt Widhalm, MD
Abstract
Kromeyer-Hausschild & Jaeger3 substantiate that
around 10% of Germany’s pupils are obese.
From January 2000 to May 2002, 59 [average Body Mass Index
Furthermore, evidence is given by longitudinal studies,
(BMI) 34] morbidly obese children and adolescents (BMI > 99th
which show that obese children will become obese
percentile) between the ages of 5.8 and 18.8 years were enrolled
adults.4,5
in a multi-disciplinary therapy program for morbidly obese children
Obese children suffer from medical consequences
and teenagers. The multi-disciplinary team (pediatrician, psycholo-
gist, dietitian and physical therapist) set up an objective to achieve
and increasing social and psychological problems.
a change in the morbid obese subjects’ handling of food by means
Morbid (extreme) obesity in childhood and youth is
of individual care. Eighty-one percent of the patients could reduce
age and sex specified and defined by a BMI > 99th
their BMI by an average of –2.01 points during the period of 7
percentile. Within the outpatient’s clinic, a special multi-
months at the end of the program. Nineteen percent maintained or
disciplinary treatment procedure consisting of dietetic,
gained weight. No correlations between BMI-difference and sex,
psychological, physical therapy and medical care was
age, time period or weight/BMI. Our results clearly show that suc-
launched for this group of patients.
cessful outpatient therapy of morbidly obese children and teenag-
ers can potentially lead to relevant success. Int Pediatr. 2004;19(2):83-
Patients
89.
Key words: morbid obesity, multidisciplinary treatment program,
The patients are exclusively referred to this program
adolescents
by a physician. The patients’ criteria for inclusion are:
BMI is exceeding the 99th percentile and a major
comorbidity (hypertension, dyslipidemia, chronic
inflammation, increased blood clotting tendency,
Introduction
endothelial dysfunction, type 2 diabetes and
hyperinsulinemia).1,6,7
Obesity (overweight) is declared as a disease by the
In 1998, five morbid obese patients visited our
World Health Organization (WHO), which is
outpatient clinic in one month. Currently there are 25
diagnosed especially in industrialized countries.1 It
new patients per month. From January 2000 to May
spreads out epidemically among children/teenagers
2002, 59 morbidly obese children and teenagers
and adults, and results from changed living habits.
between the ages of 5.8 and 18.8 years (42.4% male
Obesity has become a major political, global, public
and 57.6% female, average age 13.5 + 2.3 years) were
and health issue. The number of extreme obese children
referred. At the primary examination, the patients
and adolescents who frequently visit the outpatient’s
showed an average body weight of 92.39 + 20.59 kg
clinic for obesity and Nutrition at the Pediatrics
(203.69 + 45.39 lb), an average body height of 162.76
University of Vienna is steadily increasing. The
+ 11.20cm (64.09 + 4.41 inches) and a BMI between
prevalence of overweight children and teenagers
24.96 and 45.99 (mean BMI 34.35 + 5.01). (Table 1)
between the age of 10 and 15 years is estimated at 17-
22% while 5-11% are to be called obese.2 Studies of
Method
From the Department of Pediatrics, University of Vienna, Division of
Nutrition and Metabolism, Austria.
The multi-disciplinary team (physician, psychologist,
dietitian counselor and physical therapist) set forth the
Address reprint requests to Kurt Widhalm, MD, Department of
objective to achieve a change in a morbid obese
Pediatrics, University of Vienna, Division of Nutrition and
Metabolism, A-1090, Wahringer Gürtel 18-20, Austria.
person’s handling of food and eating by means of an
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Multi-Disciplinary Therapy Program for Morbidly Obese Children & Teenagers
individual care connected to slow weight reduction, a
is limited to three months to analyze the treatment’s
rearrangement of living and nutritional habits in the
success or failure. A prerequisite is the necessary
direction of a diverse, low-fat, and carbohydrate rich
cooperation of all family members and is checked by
diet. Three approaches have been achieved:
current exercises. In case of non-successful
development (increasing of weight, bad compliance,
• energy reduced mixed diet
missing motivation), other measures for weight
• behavioral therapy elements
reduction are recommended such as medical support,
• increased physical activity
very low-calorie diet, stationary reception in a
rehabilitation clinic, psychotherapy, etc. In case of a
(Program procedure in Table 2)
positive progress there is an additional discourse after
3 months with all family members to assure a
Detailed primary discourse. The patients are
preservation of motivation, compliance and
exclusively referred to this program by a physician and
understanding of the problem. By means of a
are informed during the first session about the
standardized questionnaire, the family’s anamnesis,
treatment program. One week later, an intensive
development, as well as nutritional habits and former
discourse with all family members (parents, siblings,
diet attempts are assessed.
grandparents, housemaid, etc.) takes place. With this
renewal, we wanted to approach all subjects who have
Outpatient sessions. Patients visited the psychological
an influence on success or failure of the treatment. An
and dietetic therapeutic sessions weekly (duration: 45
independently developed schema permits the
minutes). The psychologist and dietetic physician
registration of important parameters of all the
alternated therefore providing continuous care. Each
participants during the primary discussion: volunteering,
3rd session is held in the presence of parents and
ailing, understanding of the problem, body satisfaction,
relatives.
motivation, compliance, attitude towards sport/
Our experiences underline these postulates because
physical activity, openness, anxiety towards treatment,
a clear transparency of the training plan funds the
expectations and dynamic progress. The participation
comprehension and the willingness to support their
Table 1 - Overview on all patients’ data
N
Min.
Max.
Mean
Std.
Deviation
Age 59
5.8
18.8
13.5 2.3
Initial Height
59
125.8 cm 49.53
184.2 cm
162.76 cm
11.20 cm
inches
72.52 inches
64.08 inches
4.41 inches
Initial Weight
59
39.5 kg
142.4 kg
92.39 kg
20.59 kg
87.08 lb
313.94 lb
203.69 lb
45.39 lb
Initial BMI
59
24.96
45.99
34.35
5.01

Initial Height: Height of the child/ teenager at the beginning of the program in cm
Initial Weight: Weight of the child/teenager at the beginning of the program in cm
Initial BMI: BMI of the child/teenager at the beginning of the program
Table 2 - MO-Program process
Sessions Duration
Frequency
1. Detailed primary discourse (with psychologist and dietetic counselor)
1 ½ h
once
2. Ambulatory psychological and dietetic sessions
45 min.
weekly
3. Medical controls (blood pressure measuring, laboratory, body composition, special
1 h
every 2 months
examinations)
4. Group meetings of children and teenagers
2 h
every 2 months
5. Cooking instructions
6 h
4 x / year
6. Physical
therapy
2 h
2x / week

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Multi-Disciplinary Therapy Program for Morbidly Obese Children & Teenagers
son/daughter; especially with shopping and the choice
separation of meals, cover the main areas of the
of groceries, behavioral changes can be observed if
counseling. Types of nutrients (macro- and
the parents pick the more reasonable products already
micronutrients), energy supply and consumption,
at the supermarket and therefore avoid the unfavorable
calories and fats are illustrated by practical examples
food available at home. The parental influence on a
and illustrative material (nutrition pyramid). To
child’s physical activity is not to be underestimated (joint
implement learning, cooking instructions were offered
cycling tours, walks, running sessions). Topics like
4 times a year which were designed to deepen the
“Having to eat up”, “Eating over the hunger”, “Being
experience that low-calorie food and enjoyment are
rewarded with food in stressed situations or for good
not contradictory.
behavior” can be discussed and a consciousness for
The dietetic medical counseling had to be regarded
these problems is created. The adult role model as
as transmission of information, support and assistance,
well as very serious results of studies on adult obese
keeping in mind to change former eating habits to a
people should define overweight as a health risk.
low-fat, fruit and vegetable rich diet.
Psychological care. The primary goal is to discover
Medical controls (blood pressure measurement,
together with the child/teenager individual behavioral
laboratory, body composition, special
patterns which have led to an excessive intake of food.8,9
examinations). The complex of syndromes is now
A distinct conflict management helps to cope with
under the conception of metabolic syndrome and
predestinating problematic situations (a positive dealing
contains obesity, diabetes mellitus, hypertension,
with familiar and scholastic problems).
hyperuricemia, hypercholesterolemia, and
The patients are instructed to study new behavioral
atherosclerosis). The goal of the medical examination
manners and are supported in the realization of a
was to assess possible obesity associated diseases.
conversion of health specific behavior. Individual
A medical check-up follows each 2 months during
counseling planned the bases of living habits and the
which laboratory parameters (Cholesterol, triglycerides,
surroundings of the entire subject. Important pillars
HDL, LDL, VLDL, Lp(a) apolipoproteins A1 and B,
are the attempts to fund the ability of self-control,
CRP; Fe, uric acid, hematology and differential blood
self-consciousness and self-confidence, social
count, Vit B12, folic acid, glucose, TSH, T4, T3) are
interaction and positive coping strategies.
examined.
To distinguish success/failure, each participant
Significant components are the measuring of body
receives at the beginning a chart on which the course
height and weight, beginning of weight increase
of weight is illustrated in colors. With a slight weight
respectively of reduced/increased combustion
stagnation or reduction they can print a green mark
parameters, BMI computation, body components
with the lettering “Super” on their course protocol
analysis by means of BIA (Body Impedance Analysis),
meaning “Go for it”. A red stamp (“Stop”) with the
assessment of criteria in case of suspected PCO-
lettering “Do not give up” is used for increased weight
Syndrome with girls (Acanthosis nigricans, Hirsutism).
meaning that they should not despair but also that their
A detailed family anamnesis (weight, height,
behavior is unfavorable. They personally keep a special
cholesterol, blood pressure measuring, D.M.,
log for writing down the weight to strengthen self-
Myocardial infarction, hyperuricemia, apoplexy, pAVK,
observation and control. During each counseling
etc.) concludes the examinations.
session, an exercise is arranged (e.g. recording the
quantity and quality of hunger before a meal) and an
Group meetings of children and teenagers. The
objective for the next 2 weeks is defined.
development of common strategies for successful
Materials support a relaxed dealing with the topics
weight reduction in the group facilitates the personal
to be touched on.
access for morbid obesity. To motivate each other helps
to overcome lows and understand that nearly every
Dietetic counseling. A daily diet protocol, by means
participant has to cope with the same problems.
of which the present status quo of eating habits can
Meetings are held every six weeks and follow a specific
be assessed, plays a central role. Dietetic basics, a
order of events during which dietetic and psychological
conscious dealing with food and an adequate
interventions are set.
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Multi-Disciplinary Therapy Program for Morbidly Obese Children & Teenagers
During individual counseling an exercise is given
individually different since previous knowledge and
and later discussed in group meetings. Especially the
success/failure are taken into consideration. We take
exchange between persons concerned provides relief
care of these children for about 6-11 months, the
and encouragement.
longest for 1.5 years continuously.
During the outpatient program, the patients reduce
Physical therapy. Physical therapy is scheduled twice
their BMI on an average by –1.5, success/failure
a week in the internal gym. It helps the obese children/
fluctuates between (-8.43 and + 1.28 BMI).
teenagers to get a better feel and understanding of
Boys and girls did not differ too much in their results
their bodies. They should again have fun doing sports.
(average BMI girls = -1.3, average BMI boys = -1.43).
Everybody is motivated to keep a calendar to write
down all activity and sport sessions (gymnastic sessions
Overview on the patients who successfully
at the clinic, physical education, home training). This
participated in the MO-Program (BMI
calendar gives an overview on duration, type and
difference < 0). By means of the MO-Program, 81%
diversity of activities and can be effectively used in
of the patients (34 children & teenagers) could reduce
psychological counseling.
their BMI (BMI difference -2.01) after 7 months; 19%
(8 children & teenagers) could maintain or reduce their
Results
weight (BMI difference 0.74). Thirty-four morbid
obese children and teenagers accomplished a successful
Patients who participated in the MO-Program.
participation in the sense of a BMI reduction at the
In the consecutive computation of results only these
ages between 5.8 and 18.8 years. At the beginning of
children/teenagers were included who took part in at
the program the patients showed an average body
least 4 of the program’s counseling sessions: 71.2%
weight of 90.32 kg (199.12 lb) and a BMI between
(42 patients, 24 girls and 18 boys) completed the “MO–
24.96 and 45.99 (average BMI 33.77). (Table 4)
Program”.
Seventeen patients (28.28%, 10 female and 7 males)
Overview on the patients who could maintain their
discontinued the program or only appeared to one
BMI or whose BMI was increased (BMI
single session. (Table 3)
difference > 0). Nineteen percent of the patients (8
In total, 42 morbid obese children/teenagers at the
children and teenagers) could maintain or increased
ages between 5.8 and 18.7 years (24 girls and 18 boys,
their BMI (average BMI difference + 0.74). At the
average age 13.5 + 2.4 years) took part in the MO-
beginning of the program these patients showed an
Program during January 2000 to May 2002. At the
average body weight of 93.8 kg (206.79 lb) and a
beginning, these patients showed a body weight of
BMI between 26.27 and 38.42 (average BMI 33.88).
90.99 + 19.73 kg, an average height of 162.81 +
The program’s success or failure could not be predicted
11.56cm and a BMI between 24.96 and 45.99 (average
according to the patients’ sex, age, duration, weight or
BMI 33.79 + 4.95).
the initial BMI. (Table 5)
The amount of counseling sessions, medical
controls and physical therapeutic sessions are
Table 3 - Overview on the patients participating in the MO-Program
N
Min.
Max.
Mean
Std.
Deviation
Age
42
5.8
18.7
13.5
2.37
Initial Height
42
125.8 cm
184.2 cm
162.81 cm
11.56 cm
49.53 inches
72.52 inches
64.10 inches
4.55 inches
Initial Weight
42
39.5 kg
139.9 kg
90.99 kg
19.73 kg
87.08 lb
307.33 lb
200.60 lb
43.50 lb
Duration Mo
42
2
18
7.7
3.71
Initial BMI
42
24.96
45.99
33.79
4.95
BMI Difference
42
-8.43
1.28
-1.5
2.12
Girls
24
-8.43
1.28
-1.53

Boys
18
-6.86
0.73
-1.43


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Multi-Disciplinary Therapy Program for Morbidly Obese Children & Teenagers
Table 4 - Overview on the patients who successfully completed the MO-program (BMI Difference > 0)
N
Min.
Max.
Mean
Age
34
5.8
18.8
13.5
Initial Weight
34
39.5
139.9
90.32
87.08 lb
307.33 lb
199.12 lb
Initial BMI
34
24.96
45.99
33.77
BMI Difference
34
-8.43
-0.02
-2.01

Table 5 - Overview on the patients who could maintain or increased their BMI (BMI Difference >0)
N
Min.
Max.
Mean
Age
8
10.8
14.8
12.8
Initial BMI
8
26.27
38.42
33.88
Initial Weight
8
68.1
119.1
93.8 kg
150.14 lb
262.57 lb
206.79 lb
BMI Difference
8
0.28
1.28
0.74

Overview on the patients (28.28%), who did not
found between the age and the BMI-
participate in the MO-Program. Seventeen patients
difference (r = -0.084; p = 0.597); furthermore
(10 girls and 7 boys, 28.9%) did not participate in the
there are no age groups who give evidence
MO-Program. At the time of the primary examinations,
for relations
the patients showed an average body weight of 95.85
• Relations between BMI difference and
kg (211.31 lb), a body height of 162.6 cm (64.02 inches)
duration of participation: In our random
and a BMI between 29.26 and 44.05 (average BMI
sample no significant relations between the
35.75). Their BMI was reduced in the period of
BMI difference and the duration of the
maximum two months in spite of few (or none) set
program(r = -0.217; p < 0.174) were visible.
interventions by –0.11.
• Relation between BMI difference and initial
They discontinued the program prematurely or
body weight/BMI: The computes body
appeared only to one single session. In this context it is
weight or initial BMI are no predictor for a
important to mention that many of the potential
weight respectively a BMI reduction or
candidates could not participate in the program
increase. (Weight: r = -0.162; p = 0.36; BMI: r
because of financial reasons since the parents have to
= -0.279; p = 0.073).
cover all of the expenses. Second, most frequent reason
for a discontinuance was the time consuming procedure.
The results can be found in the literature.10,11
(Table 6)
To compare both groups (patients who
Relations within the patient group
participated in the program and those who broke off
early) would not show significant relations respectively
• Relations between BMI difference (BMI at
age, sex or initial BMI (U-test, z = -1.272, p = 0.2039).
the end minus initial BMI) and sex: 57.1%
An extensive search of the literature brought about
female and 42.9% male patients participated
that at the present time, no comparable program exists,
in the program. In the random sample, no
which is outlined for a group of patients with a BMI
significant relations between the BMI-
over 99th percentile. By means of an overview by
difference and the sex of the participants were
Reinehr12 on ambulatory treatment programs, it can
visible (r = 0.859, p < 0.05).
be concluded that only a few project managers
• Relations between BMI difference and age:
published data like the participants’ BMI progress or a
No correlations after Spearman are to be
program description. Merely the data of 4 programs
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Multi-Disciplinary Therapy Program for Morbidly Obese Children & Teenagers
is accessible (Pediatric clinic Ulm; KIDS dietetic therapy
the MO – Program showed a higher initial weight and
Koln; Moby Dick, Hamburg; Obeldicks VKK Dateln).
BMI than the ones who completed it.
In all programs the children had dietetic counseling,
Behavioral therapeutic and health psychological
84% had physical therapy and 92% had medical
elements dominate over other programs.11,13
controls.
Present reports show that only in a supporting-
Further steps would be necessary (Table 7):
familiar surrounding, weight reduction and a stagnation
of the BMI can be achieved.14-18
• Explicit descriptions of existing programs.
Because the overweight has developed and was
• Publication of results.
being maintained in familiar surroundings, by including
• Guidelines for evaluation.
the family in a long-term, an even better transfer of
• Connections between treatment facilities.
learned behavioral patters into everyday life can be
• Cooperation with established professional
ensured.17,19,20
groups.
Our results show distinctly that ambulant therapy
of obesity on morbid obese children and teenagers
Discussion
can lead over the medium term to success. For this
clinical picture valid programs have to be developed
Our study shows that by means of a
in the near future to cope with the growing number
multidisciplinary treatment program weight reduction
of people affected.
is possible in a high percentage of children and
Recommendations for the therapeutic procedure are
adolescents with morbid obesity. During the outpatient
to be found in a work by Barlow21 in which the attempt
program, the patients could reduce their BMI.
to give practical advise to the concerned professional
With regard to the BMI, no sex or age difference
teams is illustrated close to praxis.
was found, and the duration of the program had no
Golan19 compared two groups. In the experimental
influence on the BMI. The changes in the BMI during
group there were the parents; the agents of change. In
the program were not to be related to the initial BMI.
the control group each child was prescribed a diet.
Those children/teenagers who did not participate in
Golan showed that the family-based experimental
Table 6 - Overview on the patients (28.28%), who did not participate in the MO-Program
N
Min.
Max.
Mean
Std.
Deviation
Age
17
10.4
18.8
13.9
2.20
Initial Weight
17
61.1 kg
142.4 kg
95.85 kg
22.83
134.70 lb
313.94 lb
211.31 lb
50.33 lb
Initial Height
17
144.5 cm
179.8 cm
162.6 cm
10.6
56.89 inches
70.79 inches
64.02 inches
4.17 inches
Duration 17 0 2 0.1
0.83
Initial BMI
17
29.26
44.05
35.75
5.05
BMI Difference
17
-1.4
0.72
-0.11
0.5

Table 7 - Confrontation of the MO-Program with comparable programs
Outpatient programs (compare Reinehr)
Multidisciplinary MO-Program
Different compositions of teams
Multi-disciplinary team (physician, psychologist, dietetic
medical counselor, physical therapist)
N = 8-12 years
N = 10-18 years
From the 90th percentile
From the 99th percentile
3-18 months
2-18 months (7.7 months)
Success rate: 60%-95 %
Success rate: 81 %
Discontinuance rate: 1/3–60 %
Discontinuance rate: 28 %
BMI-reduction: between 0.17 and 1
BMI-reduction: -2.0

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Multi-Disciplinary Therapy Program for Morbidly Obese Children & Teenagers
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