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
Methods: We conducted a quasi-experimental study between 2012 and 2014 to investigate the effectiveness of a school-based intervention to reduce metabolic abnormalities in obese and overweight children aged 11 to 16 years in Sousse, Tunisia.
Results: Intervention group was composed of 317 and 225 schoolchildren respectively at pre and post assessment. The control group was composed of 268 and 180 schoolchildren. 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 (p < .001). Prevalence of metabolic syndrome in intervention group decreased from 7.2% to 1.8% among all participants (p = 0.10). In the control group, it increased from 4% to 7.9%.
Conclusion: A lifestyle intervention in schools could be effective to prevent obesity complications, but sustainability needs collaboration between the ministry of health and education.
Keywords: Children; Obesity; Metabolic syndrome; Management; Prevention
The increases in BMI during childhood may be related to the development and acceleration of adverse cardiometabolic risk factors, such as hypertension, dyslipidemia (high triglycerides and low high-density lipoprotein (HDL) cholesterol), hyperinsulinemia and glucose intolerance, known as Metabolic Syndrome (MS) [8].
The frequency of MS was 34.4% among obese children aged between 6 to 18 years in Tunisia [9].
This childhood epidemic of obesity and its health-related consequences in adolescents should be a clinical and public health priority. However, this major public health problem cannot be managed solely in clinical settings [10]. Furthermore, a multidisciplinary behavioral therapy can produce a significant and clinically meaningful reduction in overweight in children and adolescents [11]. Schools are an ideal site to intervene with children for the management of obesity and reduce metabolic syndrome among this high-risk population. A school-based, multi-component physical activity intervention was effective 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.
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 7th and 8th grade in selected colleges were invited to participate to the study.
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.
Session |
Target population |
Session conducted by |
Topics |
First individual consultation |
Overweight and obese participants |
Medical doctor and dietician |
First advice about healthy eating and physical activity promotion |
Second individual consultation |
Obese participants |
Psychologist |
Assessment of psychological status and psychological support
|
Third individual consultation |
Obese participants |
Dietician |
Personalized healthy diet |
Fourth individual consultation |
Obese participants |
Pediatrician |
Screening of causes and/or complication of obesity.
|
First collective session |
Overweight and obese participants |
Dietician |
Principles of healthy diet |
Second collective session |
Overweight and obese participants |
Psychologist |
Improve self esteem |
Third collective session |
Overweight and obese participants |
Medical doctor |
Snacking |
Physical activity sessions |
Overweight and obese participants |
Physical activity teachers |
Physical activity practice |
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 and control groups. The proportion of girls was 55.7% and 60.1% in the intervention and control group.
The means of Body mass index (BMI) was 25. 46 ± 3.2 in intervention group with 57.7% of overweight. It was 25.9 ± 3.9 in control group with 51.6% of overweight. Overweight represented 48.4% among boys and 58% among girls (P = 0.1) in intervention group. In control group it represented 57.4% among boys and 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).
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 [22-24]. 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].
|
Intervention group |
Control group |
||||
|
Pre intervention Mean (SD) |
Post intervention Mean (SD) |
p-value |
Pre intervention Mean (SD) |
Post intervention Mean (SD) |
p-value |
BMI Z-score |
1.88 (0.5) |
1.75 (0.6) |
< 0.001 |
1.86 (0.6) |
1.67 (0.7) |
< 0.001 |
Waist circumference (cm) |
89.5 (9.4) |
93.9 (10.3) |
< 0.001 |
88.9 (10.9) |
83.5 (10.5) |
< 0.001 |
SBP (mmHg) |
117.8 (11.1) |
115.2 (12.7) |
0.01 |
115.9 (11.3) |
117.0 (11.5) |
0.31 |
DBP (mmHg) |
68.2 (10.2) |
68.2 (13.9) |
0.99 |
69.3 (10.6) |
68.1 (13.6) |
0.31 |
|
Intervention group |
Control group |
||||
|
Pre-intervention Mean (SD) |
Post-intervention Mean (SD) |
p-value |
Pre-intervention Mean (SD) |
Post-intervention Mean (SD) |
p-value |
Glucose |
5 (0.6) |
4.96 (0.3) |
0.30 |
4.7 (0.36) |
5.1 (1.1) |
< 0.001 |
Triglycerides |
0.95 (0.48) |
0.78 (0.36) |
< 0.001 |
0.83 (0.34) |
0.85 (0.4) |
0.58 |
Total cholesterol |
4.1 (0.8) |
3.7 (0.8) |
< 0.001 |
4 (0.7) |
4 (0.8) |
0.83 |
LDL cholesterol |
2.5 (0.8) |
2.2 (0.73) |
< 0.001 |
2.4 (0.7) |
2.3 (0.7) |
0.02 |
HDL cholesterol |
1.21 (0.3) |
1.23 (0.3) |
0.43 |
1.25 (0.26) |
1.3 (0.3) |
0.005 |
Insulin |
9.1 (4.8) |
10.3 (4.9) |
0.10 |
8.6 (6.2) |
13.5 (5.2) |
< 0.001 |
|
Intervention group |
Control group |
||
|
Pre-assessment n (%) |
Post-assessment n (%) |
Pre-assessment n (%) |
Post-assessment n (%) |
Obese |
6 (11.5) |
2 (3.8) |
3 (6.1) |
7 (14.2) |
Overweight |
2 (3.4) |
0 (0.0) |
1 (2.0) |
1 (2.0) |
Total |
8 (7.2) |
2 (1.8) |
4 (4.0) |
8 (7.9) |
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.
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