# Exercise as it relates to Disease/Childhood obesity and the effects of a combined dietary–behavioral–physical activity treatment
## What is the background to this research?

According to the World Health Organisation, Obesity is defined as the accumulation of excess or abnormal body fat that may impair health.Obesity is commonly identified by measuring an individual’s Body Mass Index (BMI) or waist circumference. Obesity is caused by a sustained imbalance in energy intake and output, where the food and fluid you consume exceeds your energy expenditure It was recorded in 2010 that 43 million children were identified as obese. So it is no surprise that obesity has become a public health crisis and can lead to other chronic disease in adulthood such as diabetes, cardiovascular disease and some cancers. The objective of this study was to observe and examine what impact a 3 month multidisciplinary (diet, behavioral, and physical activity) intervention will have on obese children, where an intervention group was compared to a control group.

## Where is the research from?

This study was conducted in Israel, at the, Child and Health and Sports Centre. Israel is the leading country in childhood obesity in Europe according to the World Obesity Federation. The selection criteria was based on previous interventions involving body weight and BMI changes Two intervention groups participated in the 3-month multidisciplinary (diet, behavior, physical activity) intervention and the control group had no involvement. The study was approved by the Meir General Hospital and supported by the Tel-Aviv University where one of the authors (Dan Nemet) was employed potentially creating a bias in the research. Dan Nemet is well respected, contributing to 213 publications

## What kind of research was this?

The study was undertaken as a randomized prospective study where 24 obese children completed a 3 month multidisciplinary intervention and were compared with 22 obese control age and gender matched subjects

## What did the research involve?

The purpose of this study was to examine the short and long term effects of a 3-month, combined dietary-behavioral-physical activity intervention on antrhopometric measures, body composition, dietary and leisure-time habits, fitness, and lipid profiles among obese children
The subjects included 54 self-referred children and adolescents all aged between 6-16 years old. 30 subjects in the intervention group with 24 completed the 3 month intervention, 6 subjects dropped out and 20 returned for the evaluation 1 year later. 24 subjects were assigned as the control group and were told to complete physical activity 3 times a week on their own. 22 completed the intervention and 20 returned for the 1 year evaluation. The intervention consisted of 4 lectures based on childhood obesity, general nutrition, a therapeutic nutritional approach for childhood obesity, and exercise and childhood obesity.
The dietary intervention included 6 appointments throughout the 3 months program with a qualified dietitian. Subjects between the ages of 6-8 were accompanied by their parents, subjects > 8 years were accompanied with parents for the first 2 appointments then attended them alone. Families were instructed to attend the first meeting to educate them on obesity and was aimed to encourage the whole family to participate in the “battle” against obesity. Subjects were provided a balanced hypocaloric diet consisting of 5021 – 8368 kJ and intake 15% less than the recommended daily intake.
Exercise program included 1 hour sessions, twice a week and were conducted by professional youth coaches at the Child Health and Sports Center. The aim of the exercise program was to imitate the physical activity intensity normally performed by elementary and high school children. To keep the children engaged endurance type activities were designed as games with attention to coordination and flexibility. Subjects were encouraged to keep active whilst at home by adding an extra 30 to 45 mins of physical activity at least once per week. These activities were assessed by the coaches at the end of each session. Fitness was evaluated with a progressive treadmill test to estimate exercise endurance. Results were compared to their results from before they started the intervention.
Habitual activity was monitored and evaluated by using physical activity questionnaires. Each type of physical activity was scored according to an estimated metabolic rate equivalent score and a final weighted score was calculated.

## What were the basic results?

Positive significant changes were seen in the intervention group, in regards to body weight, BMI, and body fat percentage. There were also significant decreases in daily intake and habitual activity amongst the intervention group for both short and long term results. In contrast there was significant increases amongst the control group in relations to body weight, and body fat percentage
| Control Group | Before | After |
| Body Weight (kg) | 63.4 ± 22.8 | 64.5 ± 24.1 |
| BMI (kg/m²) | 27.8 ± 5.0 | 27.6 ± 5.6 |
| Body Fat % | 40.7 ± 7.9 | 42.2 ± 9.9 |
| Caloric intake | 8335 ± 1741 | 6602 ± 1439* |
| Habitual activity (units) | 24.3 ± 20.1 | 22.1 ± 16.9 |
| Intervention Group | Before | After |
| Body Weight (kg) | 63.8 ± 19.1 | 61.0 ± 18.3 |
| BMI (kg/m²) | 28.5 ± 4.1 | 26.8 ± 3.9 |
| Body Fat % | 40.2 ± 7.3 | 36.9 ± 8.0 |
| Caloric intake | 7519 ± 1569 | 5887 ± 1305* |
| Habitual activity (units) | 22.5 ± 12.5 | 45.7 ± 12.6* |
Although there is no cure for obesity, it is a preventable disease and these results prove that a multidisciplinary approach is beneficial for obese children and adolescents. Treatment for obesity in children and adolescents should involve dietary changes, nutritional education, changes in physical activity patterns, behavioral modifications and parental involvement.

## What conclusions can we take from this research?

From this study, it can be concluded that a multidisciplinary intervention consisting of diet, behavioural and physical activity components can help reduce the obesity prevalence. The benefits could include weight loss, reduced BMI, reduced body fat, lower daily caloric intake, higher energy expenditure, less sedentary time and more physical activity. Therefore, reducing the risks of children becoming obese in the future as adults and reducing the risks of being diagnosed with associated disease such as cardiovascular disease, diabetes, hypertension, and some cancers.

## Practical advice

Although this study indicates that a diet-behavioural-physical activity intervention can help reduce the prevalence of obesity, it fails to consider the socio-economic status, ethnicity and location of the subjects that were involved in this study. It was recorded that 46% of Indigenous Australian youth were identified as obese and socioeconomic status, english as 2nd language and rural location was a factor of high BMI Parents should encourage their children to walk to school and pack healthy lunches to instill good habits from a young age. Reducing TV viewing and increasing physical activity in an enjoyable way will assist to reverse the prevalence of obesity in children.

## Further readings

* The childhood obesity plan - https://www.kingsfund.org.uk/blog/2016/08/childhood-obesity-plan
* https://www.obesityaustralia.org/
* WHO - Plan of Action for the prevention of Obesity in Children and Adolescents - https://www.paho.org/hq/dmdocuments/2015/Obesity-Plan-Of-Action-Child-Eng-2015.pdf?ua=1

## References

Add in the references using this code
* 1 2 Obesity and overweight [Internet]. World Health Organisation. 2018 [cited 16 August 2018]. Available from: http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
* 1 2 3 4 Ebbeling C, Pawlak D, Ludwig D. Childhood obesity: public-health crisis, common sense cure. The Lancet [Internet]. 2002;360(9331):473-482. Available from: https://www.sciencedirect.com/science/article/pii/S0140673602096782
* ↑ Wang Y, Lim H. The global childhood obesity epidemic and the association between socio-economic status and childhood obesity. International Review of Psychiatry [Internet]. 2012;24(3):176-188. Available from: https://www.tandfonline.com/doi/citedby/10.3109/09540261.2012.688195?scroll=top&needAccess=true
* 1 2 Elizera R. Isreal leading Europe childhood obesity. ynetnewscom. 2016;.
* 1 2 3 4 5 Nemet D, Barkan S, Epstein Y, Friedland O, Kowen G, Eliakim A. Short- and Long-Term Beneficial Effects of a Combined Dietary-Behavioral-Physical Activity Intervention for the Treatment of Childhood Obesity. PEDIATRICS. 2005;115(4):e443-e449.
* ↑ Nemet D, Barkan S, Epstein Y, Friedland O, Kowen G, Eliakim A. Short- and Long-Term Beneficial Effects of a Combined Dietary-Behavioral-Physical Activity Intervention for the Treatment of Childhood Obesity. PEDIATRICS. 2005;115(4):e443-e449.
* ↑ O'Dea J. Gender, ethnicity, culture and social class influences on childhood obesity among Australian schoolchildren: implications for treatment, prevention and community education. Health & Social Care in the Community. 2008;16(3):282-290.
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