Beneficial Effects of a 1-Year Lifestyle Intervention on Metabolic Abnormalities in Overweight and Obese Schoolchildren in Sousse Tunisia : A Pre-Post Quasi-Experimental Study with Control Group

1Department of Epidemiology, University Hospital Farhat Hached Sousse, Tunisia 2Department of Pediatrics, University Hospital Farhat Hached Sousse, Tunisia 3World Health Organization Office Eastern Mediterranean Region, Non-Communicable Diseases Management Unit, Cairo, Egypt 4Pediatric Cardiology Unit, Department of Child and Adolescent University Hospitals of Geneva, University of Geneva, Geneva, Switzerland Journal of Endocrinology and Diabetes Open Access Research Article


Introduction
The prevalence of obesity in children has increased worldwide during the most recent decades [1].Up to 20% of children in several Western European countries are overweight, and the to decreasing levels of BMI, skinfold thickness, fasting glucose and increasing the duration of moderate and vigorous physical activity [12].The majority of children are enrolled in schools and this provides access to children and enables repeated exposure to health promotion interventions [13].
Therefore, the purpose of this project was to investigate changes in metabolic syndrome in overweight and obese adolescents after one year of multidisciplinary lifestyle intervention in schools in the region of Sousse, Tunisia.

Study design
We conducted a quasi-experimental study between 2012 and 2014 to investigate the effectiveness of a school-based intervention to change lifestyle habits and consequently reduce metabolic abnormalities in obese and overweight children in Sousse, Tunisia.The intervention group was located in four schools in the delegation of Sousse Jawhara and Sousse Erriadh and control group was located in two schools in the delegation of Msaken (Table 1).
Sample size estimates were based on a significance level of 0.05 and 80% power to detect a difference between groups of 0.15 in BMI Z-score after the one-year intervention.Assuming a failure to consent rate of 10% (not eligible as well as declining to participate) and a dropout rate of 10%, 250 participants in each group were needed.All overweight and obese schoolchildren enrolled in 7 th and 8 th grade in selected colleges were invited to participate to the study.

Definition of variables
Body Mass Index (BMI) was calculated as weight (kg)/ height² (m²) and z-scores were derived using the World Health Organization references [14].Overweight was defined as BMI between 1 and 1.99 SD and obesity above 2 SD.Metabolic syndrome was defined according to the International Diabetes Federation (IDF) criteria [15].

Intervention program
Before the beginning of the project, we contacted directors of all participant colleges in an intervention group to have their consent and evaluate their needs.We offered equipment for physical activity to schools to improve this activity for excess weight children.The project team participating in the intervention was composed of medical doctors (general practitioner, epidemiologist and pediatricians), dieticians, physical activity teachers and psychologist.During the intervention, recruited overweight and obese school adolescents participated to an integrative approach including cognitive behavioral techniques based on CONTREPOIDS © program [16] which was developed according to the current evidence on obesity treatment [17].There were been two intervention strategies: A group intervention for all recruited children (overweight and obese) and an additional individual intervention for obese children who require an intensive therapy.Overweight and obese adolescents in intervention schools were invited to participate to group sessions including 7 to15 subjects.Three types of group sessions were been organized for overweight and obese participants.

• First collective session animated by a dietician in schools:
healthy diet for overweight and obese children.
• Second Collective session animated by a psychologist in schools to improve self esteem among overweight and obese children.
• Third collective session animated by a medical doctor about snacking for overweight and obese children.
The individual intervention was composed of four consultations during the program.The first consultation targeted all participants (overweight and obese) and the other consultations targeted only obese participants.
• The first advice took place just after data collection about eating habits and physical activity.It concerns both overweight and obese participants.
• Second Individual consultation with a psychologist: assessment of psychological status (screening of depression or low self esteem level) and psychological support for obese participants in intervention group.
In the case of problem, the children were addressed for psychological care.
• Third individual consultation with the dietician (for obese children): personalized healthy diet for each obese participant according to his eating habits and BMI.
• Fourth individual consultation for obese children with pediatrician: screening of causes for obesity such as hypothyroidism and/or complication of obesity; education and motivation to follow a healthy diet and regular physical activity.
Program of twice a week additional physical activity sessions in schools coached by physical activity teachers for overweight and obese children: Physical teachers confirmed that they continue to deliver 2h per week of physical activity to the enrolled students if they come to the session.
We collected biometric measures such as height, weight and waist circumference.Body weight was recorded to the nearest 0.1 kg using portable electronic scale Beurer ps 07.Standing height was measured with the participants in bare feet to the nearest 0.5 cm.Waist circumference was measured to the nearest 0.1 cm using a non stretchable standard tape measure.The measurement was been taken over a light article of clothing, just above the uppermost lateral border of the right Ilium, at the end of a normal expiration.Blood pressure was measured with Omron digital blood pressure monitor at rest.Plasma glucose, total cholesterol, LDL and HDL-cholesterol and triglyceride concentrations were measured by enzymatic methods among all participants.Plasma Insulin level was measured only among obese participants.Blood samples were collected in the morning and after overnight fasting.
In the control group, we did not intervene during the study.We just referred overweight and obese children to school medical doctor.

Outcomes measures
We collected data before and at the end of the intervention both in intervention and control groups.

Statistical analyzes
We used SPSS v.10.0Software for data capture and analysis.A p < 0.05 was considered statistically significant for all tests.We used paired sample t test and Chi square MacNemar test respectively to compare means and percentages at pre and post assessment in each group.

Ethical consideration
The protocol was approved by the Ethical Committee of the University Hospital Farhat Hached.We obtained children and parents free, informed consent before the participation to the study.In the control area, all screened obese and overweight schoolchildren are been addressed to school medical doctor with the result of biomedical measures for potential management.We offered a delayed intervention in the control group after the end of the project.

Results
The intervention group was composed of 317 and 225 overweight and obese schoolchildren respectively at pre and post assessment.The control group was composed of 268 and 180 overweight and obese schoolchildren respectively at pre and post assessment (figure 1).
The mean of BMI Z-score of drop out participants was 1.86 ± 0.5 vs 1.88 ± 0.5 among those who were present at post assessment (after one year intervention) in intervention group (P = 0.79).In control group, the mean of BMI Z score among drop out participants was 1.78 ± 0.6 vs 1.86 ± 0.6 among those who were present at follow up (P = .33).The mean age of participants was respectively 13.2 ± 0.98 and 13.6 ± 0.96 years in intervention

59.6% among girls (P = 0.7).
The mean of Body mass index Z-score and waist circumference decreased significantly from pre-intervention to post-intervention both in intervention and control groups.Systolic blood pressure (SBP) decreased in intervention group significantly from 117.8 to 115.2 mmHg (P = 0.01) (Table 2).
Blood glucose and insulin level decreased in intervention group and increased significantly in control group.Triglyceride, total cholesterol and LDL cholesterol decreased significantly in intervention group.In control group, only LDL cholesterol decreased significantly (Table 3).
Prevalence of metabolic syndrome in intervention group was 7.2% in all participants, with 11.5% among obese and 3.4% among overweight.At the end of the intervention, it decreased to 1.8 % among all participants (P = 0.10).In control group, metabolic syndrome was present among 3% of participants with 4% and 2% respectively among obese and overweight.At post assessment, it increased to 5% among all participants (Table 4).

Discussion
This school-based lifestyle intervention for excess weight management reduced the prevalence of metabolic syndrome among schoolchildren and improves metabolic parameters.To our knowledge, this is the first multidisciplinary intervention conducted in school settings to manage excess weight in our country.Even though we faced a lot of difficulties in the implementation of this intervention study mainly due to the busy schedule of children, inappropriate environment and lack of motivation of some participants, we were able to demonstrate the feasibility of such intervention.Schools, where children and adolescents spend the majority of their time, are promising venues for intervention work [18].A report of Institute of Medicine cited that schools as a "national focal point" could address obesity in children and adolescents [19].As several systematic reviews demonstrate, however, there is a paucity of obesity intervention research in school settings [20,21].Some authors proposed a school-based health centers that have several compelling features for a successful lifestyle intervention program to treat overweight/obesity and prevent development of metabolic syndrome [22].In these schools, clinicians have more access to adolescents than community health care providers; adolescents have better compliance and follow up in school-based clinics; and it's possible to focus on early identification of high-risk problems [22][23][24].Conducting research in partnership with the school-based health centers, the school administration, the students, and their families poses a set of logistical and study design challenges [25].
A recent systematic review has reported that lifestyle interventions incorporating dietary and exercise components with or without behavior therapy would lead to improvement of weight and cardio-metabolic outcomes among children [26][27].Some interventions used out of school activities and involvement of parents [28].Both these approaches were found to be beneficial.The majority of the interventions focused on individual level behavior change approaches and few addressed broader policy and environmental level changes [28].The majority of the interventions utilized existing teachers for implementation of the interventions [28].
Nevertheless, almost 80% of pediatricians report frustration with their ability to make an impact on obesity [29] and many providers feel they do not have the tools to effectively address lifestyle modification for weight loss [30].A recent Cochrane review evaluated sixty-four randomized controlled trials in community setting of educational, behavioral and health promotion interventions for childhood obesity [31].Authors concluded that comprehensive interventions with family implication to promote healthy diet and physical activity with psycho-social support were more effective than those targeting only the obese child [31].
In our study, we observed a significant decrease of BMI Z-score both in intervention and control groups.We think that it could due to Hawthorne effect.In fact, we observed a high level of motivation among control group to lose weight.Indeed, the majority of interventional studies have shown that without treatment, BMI z-scores increases [31].
In other hand, we recognize that this intervention didn't show a significant decrease of MS in intervention group, nevertheless it increased in control group.The main limitation of this study was the absence of randomization and a quasi-experimental design couldn't insure the intervention effect.
A lifestyle intervention in schools is feasible and could be effective to help health professionals in decreasing obesity and preventing its complications.However, the implication and collaboration between the ministry of health and education is needed to sustain this action.

00134 Beneficial Effects of a 1-Year Lifestyle Intervention on Metabolic Abnormalities in Overweight and Obese Schoolchildren in Sousse Tunisia: A Pre-Post Quasi-Experimental Study with Control Group Copyright: © 2015 Maatoug et al.Table 1 :
Lifestyle intervention program for weight management among overweight and obese schoolchildren in Sousse, Tunisia, 2012-2014.

00134 Beneficial Effects of a 1-Year Lifestyle Intervention on Metabolic Abnormalities in Overweight and Obese Schoolchildren in Sousse Tunisia: A Pre-Post Quasi-Experimental Study with Control Group Copyright: © 2015 Maatoug et al.
Figure 1: Participation rate of school children at pre and post assessment in the lifestyle intervention on metabolic abnormalities in overweight and obese schoolchildren in Sousse Tunisia, 2012-2014.Metabolic Abnormalities in Overweight and Obese Schoolchildren in Sousse Tunisia: A Pre-Post Quasi-Experimental Study with Control Group.J Endocrinol Diab 2(5): 1-6.DOI: http://dx.doi.org/10.15226/2374-6890/2/5/

Table 2 :
Evolution of the anthropometric parameters before and after the intervention conducted in the region of Sousse to manage obesity among schoolchildren, 2012-2014.

Table 3 :
Evolution of the metabolic parameters before and after the intervention conducted in the region of Sousse to manage obesity among schoolchildren 2012-2014.

Table 4 :
Evolution of metabolic syndrome among overweight and obese participants in intervention and control groups.