The study is being conducted with significant support from Dr.-Karl Wilder Foundation, Berlin, instead of. The steady increase in the prevalence of obesity in child-. Adolescence makes an early prevention necessary. A large proportion of these overweight adolescents will also be overweight as adults (Bar – Or, 1998[1]; Maffeis et al., 1998 [14]; Whitaker et al., 1997 [21]). The effects of obesity on morbidity and mortality have been widely documented (Figueroa – Colon, 1997[6]; Srinivasan et al., 1996 [19]; Freedman et al., 1985 [7]; Power et al., 1997 [16]). Studies show that the daily exercise time of children and adolescents is constantly decreasing (Grilo et al., 1993 [8]; Guidelines for school and health programs to promote lifelong physical activity among young people, 1997 [9]; Physical Activity and Health Report, 1996 [15]) and at the same time the intake of high-energy foods and of fast-food products is increasing (WHO Technical Report Series, 2000[22]). Calculations for Germany assume, if the prevalence of obesity in adults does not increase, that in 2030 the total cost of sog. Early-onset obesity including comorbidity by ca. 50% increase (Schneider R., 1996 [17]).
Description of the outpatient therapy program FITOC
In Freiburg, since 1987, the interdisciplinary therapy program FITOC (Freiburg Intervention Trial for Obese Children) (acute treatment phase 8 months, follow-up phase 4 months and longer) overweight children aged 8-11 years who are above the 97. BMI – percentile lying, therapies. Since 1990, the data of 364 children from 21 groups, who had started treatment at different times, have been recorded in this way. The children are seen by a network consisting of pediatricians in private practice, school medical service, pediatric clinic, child and adolescent psychiatry and counseling services of the special outpatient clinic of the o.G. Department referred. The program includes a regular physical education class (3x per week) as well as extensive nutrition and behavioral education (7 parent education sessions and 7 child education afternoons). Within the parent training courses, in addition to theoretical. Practical information to the nutrition the various backgrounds of the Adipositas reworked. Anthropometric, biochemical and performance medical parameters are collected at the initial examination (EU) and control examinations (KU). Further information is provided by nutritional protocols and questionnaires. Based on the child's development, a new orientation for the child and parents is worked out at each checkup. Since the children are still growing, a moderate weight reduction or stability of body weight leads to the desired success in the long term. Due to the intensive nutritional and behavioral training, the children learn to control themselves (self-control techniques) and to implement individual recommendations according to their personal situation and to establish these recommendations in the long term. The regular sport leads to an increase in self-confidence, while at the same time increasing energy consumption. The treatment team consists of a physician, oecotrophologist, physical education teacher and psychologist. In 1997, the program was initially handed over to various multiplier teams in the Freiburg area. For this purpose, the out-of-town caregiver teams completed an Aus-. Continuing education in the form of training. A manual, forms and a set of slides were made available as working material, so that quality assurance can be carried out via the department Rehabilitative and preventive sports medicine is guaranteed. In the meantime, other multiplier groups are working according to the same principle in different regions of Germany. Initial control studies show that the outpatient therapy program is transferable and, after appropriate training, other users can also demonstrate comparable therapy experience and results Initially, 20 multiplier groups are to be evaluated centrally via Freiburg. A nationwide dissemination is aimed at. (Korsten-Reck et al., 1997[11]; Korsten-Reck et al., 1998[12]; Traencker, 1997 [20]). In the following, the short- and long-term results of the Freiburg therapy program and, as an example, the results of the Düren multiplier group are presented.
Method
Success is defined according to the guidelines of FITOC: Weight stability with length growth or weight reduction. Accordingly, failure is defined as a relative weight gain during the program over the periods studied. The weight development is assessed on the basis of the BMI-SDS at the different examination times. BMI-SDS is calculated as follows: SDS = [(BMI/M(t))L(t)-1]/L(t)S(t) where BMI is the child's individual BMI value [weight(kg)/height2(m2)]; L(t), M(t), S(t) are the L (Box-Cox transformation), M (median) and S (coefficient of variation) values of the reference group for the respective age (t) and sex. As reference values, the BMI percentiles of German children recommended in the guidelines of the Arbeitsgemeinschaft Adipositas im Kindes- und Jugendalter (s. Also Kromeyer-Hauschild et al. [13] (2001); Cole[4](1990) used. Cholesterol was measured with an enzymatic color test (Cholesterol CHOD-PAP method); LDL cholesterol as well as HDL cholesterol with an electrophoretic method (Helena REP Diagnostic, Greiner Bio Chemica). Using a standardized bicycle ergometry (Lode, Groningen NL, speed-independent bicycle ergometer, ECG, Hellige six-unit recorder, 3-min.Scheme), physical fitness was measured.
Statistics The T-test for dependent samples was used to test the differences in the examined parameters between the initial and control examination after the end of the intensive phase of the program (KU) for significance. Analysis of variance for repeated measures followed by the Bonferroni test was used to test for significance of differences between more than two study time points. The chi2 test was used to determine the differences between the sexes in the frequency of success or failure. Failure in weight development to be tested for significance. For all statistical tests, a significance level of 5% was assumed.
Multiplication group Düren The outpatient and sports-oriented program was carried out in Düren in accordance with the training content according to FITOC (sports 3 times a week, practical and theoretical nutritional advice for parents and children, psychological support, individually and in groups). The group from Düren consists of 12 boys and 4 girls (mean age = 10.67 years). At the initial medical examination and the control examination, the following parameters were measured analogously to the groups in Freiburg: Height, weight, total cholesterol, LDL and HDL cholesterol, watt/kg body weight.
Results and discussion
The general characteristic features of the groups are described below. 21 groups (ntotal =364; m=176, w=188) participated in the FITOC entrance examination. An evaluation of the changes between initial (EU) and control examinations (KU) after the intensive program is possible for 19 groups, since up to this point in the evaluation only these groups had completed the intensive phase (as of May 2001: ntotal=324; m=155, w=169). In the 19 groups, a total of 295 children (91.0%); (male n=143 (92.3%), female n=152 (89.9%) completed the program regularly. Age at entry examination was 10.8 ± 1.5 years for boys and 10.4 ± 1.6 years for girls. The interval between initial and follow-up medical examinations is 9.0 ± 1.9 months. The goal of the program is to conduct the first control examination after 8 months. Logistic requirements can be u.A. Lead to a postponement of the examination dates. Tab. 1 : BMI-SDS changes between the initial examination and the control examination after the intensive phase Boys Girls Total
Dropout n 12 17 29 % 7,7 10,1 9,0
BMI-SDSKU*>BMI-SDSEU° n 27 37 64 (failure) % 17,4 21,9 19,8
BMI-SDSKU* n 116 115 231 (success) % 74,8 68,0 71,3
Total n 155 169 324 % 100 100 * – BMI-SDSKU; BMI-SDS at control examination (9.0± 1.9 months) ° – BMI-SDSEU; BMI-SDS at initial examination
Of the group, more than 70% of the children have a therapeutic success (Tab 1). There are no significant gender differences (chi2 test; p=0.401). No studies are known that show a comparable success. Table 2 shows the frequencies of BMI-SDS decreases resp. Increases from the initial examination to the follow-up examination after 3.1 ± 0.7 years (the time interval to the end of the intensive phase of the program averaged 2.4 ± 0.7 years) presented. An assessment of long-term results is possible for 14 groups with a total of 238 children, since the remaining groups were established later and do not yet have repeat examinations after such a long period of time. For a total of 118 children (ca. 50%) long-term results are available. There is a significant gender difference in the frequency of BMI-SDS increases and decreases. Decreases between the follow-up examination after 3.1 years (FO) and the initial examination (EU) (chi2 test; p=0.001). Here, boys are more successful than girls in the long run, d. H. The majority of the boys measured were still alive after ca. 3 years a lower BMI-SDS than at program entry. These differences between boys and girls in stabilization or further improvement in program outcomes could u. A. Be due to gender-specific attitudes towards active physical activity. Statistics from the German Sports Federation show that girls generally participate less in sports and are also less involved in clubs (Deutscher Sportbund, 2001 [5]). The socialization of girls and boys (doing gender) indicates a different importance of sports at an early stage (Horstkemper and Zimmermann, 1998[10]). Girls are less likely than boys to define themselves by physical activity. It remains open whether the inadequate sports offer for girls is a consequence or cause of this development. When assessing treatment success, endocrinological differences between the sexes, which also have an impact on the change in body fat mass, must also be discussed (Wilmore and Costill, 1994 [23]) Tab. 2 : BMI-SDS changes between the follow-up examination after 3.1 years (FO) and the initial examination (EU) Boys Girls Total
No measurement n 51 69 120 % 42,1 59,0 50,4
BMI-SDSFO*>BMI-SDSEU° n 24 28 52 (failure) % 19,8 23,9 21,8
BMI-SDSFO* n 46 20 66 (success) % 38,0 17,1 27,7
Total n 121 117 238 % 100 100 * – BMI-SDSFO; BMI-SDS at follow-up examination (3.1± 0.7 years) ° – BMI-SDSEU; BMI-SDS at initial examination
In addition to weight management, the goals of the intervention program include an improvement in the cardiovascular risk profile, an improvement in physical fitness and, associated with this, an increase in quality of life. Table 3 shows the data of BMI-SDS, total cholesterol, LDL cholesterol, HDL cholesterol, and watt/kg body weight at the initial (EU) and control (KU) examination. Highly significant changes are shown in both genders for BMI-SDS and fitness (p
In the following the results of the Düren multiplier group are described. Overall, the therapy is successful for the Düren group (Tab. 5 ). There is a significant decrease in BMI-SDS (p=0.004) from baseline (2.4) to follow-up (2.2). Further improvements are seen in the area of fitness (pN Mean value EU SD EU Mean value KU SD KU p – value
BMI-SDS 16 2,4 0,4 2,2 0,5 0,004
LDL (mg/dl) 16 117,8 25,4 110,5 28,0 0,07
HDL (mg/dl) 16 48,0 16,2 49,9 15,9 0,5
Watt/ kg 16 1,5 0,4 2,3 0,6 < 0,001
Summary
To demonstrate that it is possible to successfully treat children with the chronic disease obesity in a long-term interdisciplinary intervention program. The question also arises as to the transferability of FITOC to other regions of Germany. Children aged 8-11 years above the 97th percentile are included in the program.BMI percentiles recorded. To verify the set goals with weight management, increase of physical activity and improvement of the risk profile, height and weight were measured (BMI) and a fasting blood draw, a standardized ergometry and a medical examination were performed before, after intervention and at all further check-ups. The measured medical data show that the intervention leads to a significant improvement in all areas reviewed. This does not only refer to the intervention period of 8 months, but can still be observed after approx. 2.5 years could be demonstrated as long-term success. The other components of the intervention such as nutrition. Psychology are not presented in this study. The results of the psychological work in FITOC will be evaluated in the future using standardized instruments. In the case of the Düren multiplier group, a therapeutic success of the group according to the definition of the FITOC program can also be demonstrated. This shows that FITOC is transferable to all regions of Germany with appropriate structural conditions with intensive training of the teams. FITOC is able to successfully treat obese children in the long run. Given the increasing prevalence of childhood obesity and limited financial resources in the health care system, the outpatient interdisciplinary program is an effective treatment modality.
Summary
In this study first we try to answer the question, wether it is possible to make a successful treatment for obese children in an interdisciplinary program. Second it is asked, wether a transfer of this program to further regions in Germany leads to comparable results. In FITOC children from the age of 8 – 11 years and over the 97. BMI-percentile are integrated in this program. The goals weight management, increased physical fitness and improvement of the cardiac risk profile are checked by weight, height, fasting blood serum, a standardised cycle ergometry and a medical measurement at the beginning, after treatment and at all check-ups. The recorded medical datas show clearly that the intervention leads to a significant improvement in almost all checked parts. The successful treatment can be recorded after 8 months, likewise after 2.5 years as a longterm result. The further cornerstones of FITOC nutrition and psychology are not subject in this publication. In future the psychological part in FITOC will be evaluated by standardised inventories. The group from Düren has a success in therapy according to the definition of the program. Thereby it is shown that FITOC is extendible, if teams are trained intensively and the conditions are comparable. FITOC is able to treat obese children successfully over a long period of time. In consideration of the rising prevalence of obesity in childhood and the limited financial resources in health care this outpatient interdisciplinary program is an effective choice of treatment.
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