EASO Award Application, Attachment 3 Nowicka
Multidisciplinary approaches in a clinical setting
Paulina Nowicka, Ph.D. student 1, 2 .
Supervisors: Carl-Erik Flodmark MD PhD 2 , Tomas Sveger MD, PhD 1 and Erwin Apitzsch PhD 3 .
1 Department of Pediatrics, Malmö, Lund University, Sweden
2 Childhood Obesity Unit, University Hospital Malmö, Malmö, Sweden.
3 Department of Psychology, Lund University, Lund, Sweden
Background
Obesity in children is a worldwide disease. Despite recent reports that childhood obesity might be leveling off (1-3), almost 20% of children in Sweden are overweight, including 4-5% who have developed obesity (4). Diseases caused by the recent obesity epidemic have not yet had time to develop, as this takes 40-50 years (5, 6). Being overweight as a child or adolescent can significantly impact psychological well-being (7). It has been shown that obese children in a clinical sample have lower health-related quality of life than children diagnosed with cancer, undergoing chemotherapy
(8). Further, a great proportion of obese children have impaired glucose tolerance as well as hypertension, dyslipidemia and other risk factors (9-11). Moreover, obesity in childhood and adolescence has been associated with higher morbidity and mortality in adult life (5, 6, 12).
1
Interventions aimed at childhood obesity include prevention and treatment (13). Both prevention and treatment need improvement to be useful in the clinical setting (14, 15). Very few investigators have demonstrated that treatment is effective (16-18). The main criticism of the outcome research has been the lack of generalizability to everyday practice. Sampling problems in many studies may underline the difficulties in making generalizations – the best research in the field has been conducted in populations who are most likely to respond to interventions, such as motivated white educated middle-class families (15). Only recently has evidence of feasibility and effectiveness, taking both practicalities and cost-effectiveness into account in the context of health services, been tested in a limited number of studies (19, 20).
Aims of the thesis
Since the increasing prevalence of childhood obesity stays in contrast with treatment possibilities it is necessary to continue to design and implement cost-effective treatment strategies. It is especially important to focus on children with a higher degree of obesity and on adolescents, since there are very few successful treatment methods for these groups. Equally important is the further focus on generalizability of treatment results and feasibility in other health care settings.
The overall aim of the thesis is to develop and evaluate treatment programmes for obese children and adolescents. The focus was on generalization of the treatment in a clinical setting as well as an analysis of what factors might explain and influence the results. The thesis will be based on the following publications:
I. Nowicka, P. Pietrobelli, A. Flodmark, CE. “Low intensity family therapy is useful in a clinical setting to treat obese and extremely obese children.” International Journal of Pediatric Obesity
2007;2:211-7
II.Nowicka, P. Höglund, P, Pietrobelli, A. Lissau, I. Flodmark, CE. “Family Weight School treatment:
1-year results in obese adolescents”. International Journal of Pediatric Obesity. 2008; 3: 141-147
III. Nowicka, P. Höglund, P, Birgerstam, P. Lissau, I. Pietrobelli, A. Flodmark, CE. "Self-esteem in a clinical sample of morbidly obese children and adolescents". Acta Paediatrica, 2008 Oct 6.
[Epub ahead of print]
IV. Nowicka, P. Lanke J. Pietrobelli, A. Apitzsch, E. Flodmark, CE. “Sports camp with 6 months of support from a local sports club as a treatment of childhood obesity”. Submitted to Scandinavian
Journal of Medicine and Science in Sports.
V. Nowicka, P. Flodmark, CE. “How to work with family – A library of useful tools in childhood
obesity” (Working title). Manuscript.

EASO Award Application, Attachment 3 Nowicka
Methods and Results
I. The aim of this study was to assess the effect on BMI z-scores and self-esteem of low-intensity solution-focused family therapy in obese and extremely obese pediatric subjects. Fifty-four obese children, aged 6-17 years, were referred to an outpatient obesity clinic. The families received solution-focused family therapy provided by a multidisciplinary team. Height and weight were recorded; BMI and BMI z-scores were derived. Self-esteem was assessed with a validated
2 questionnaire, “I Think I Am.” Parents completed “The Family Climate Scale” assessing family dynamics. Eighty-one percent of the children (n=44, mean age 11.9 years, mean BMI z-score 3.67, range 2.46-5.48) and their parents participated in the follow-up. Eleven children were treated for 6-12 months, and 33 for more than 12 months. On average, the families received 3.8 family therapy sessions. Intervention resulted in a mean decrease in BMI z-score of 0.12 (p=0.0001). Self-esteem on the global scale improved after intervention (p=0.002), and likewise on sub-scales depicting physical characteristics (p<0.001), psychological well-being (p=0.026), and relations with others (p=0.046).
The Family Climate Scale showed improvement in the sub-scales for Expressiveness (p=0.002) and
Chaos (p=0.002).
In conclusion, this study indicates that it may be possible to treat pediatric obesity in a clinical setting with only four sessions through a multidisciplinary team approach. A small but significant decrease in
BMI z-score was found. Self-esteem in the children improved, as did family functioning assessed by parents.
II. The aim of this study was to evaluate the efficacy of a Family Weight School treatment based on family therapy in group meetings with adolescents with a high degree of obesity. Seventy-two obese adolescents aged 12-19 years were referred to a childhood obesity center by pediatricians and school nurses and offered a Family Weight School therapy program in group meetings given by a multidisciplinary team. Intervention was compared with an untreated waiting list control group collected consecutively after the inclusion of the last participant in the Family Weight School. Body mass index and BMI z-scores were calculated before and after intervention. Ninety percent of the intervention group completed the program (34 boys, 31 girls; baseline age 14.8 ±1.8 years (mean ±
SD), BMI 34.6 ± 4.0, BMI z-score 3.3 ± 0.4). In the control group, 10 boys and 13 girls (baseline age
14.3 ± 1.6, BMI 34.1 ± 4.8, BMI z-score 3.2 ± 0.4) participated in the 1-year follow-up. Adolescents in the intervention group with initial BMI z-score < 3.5 (n=49 out of 65, baseline mean age 14.8, mean BMI 33.0, mean BMI z-score 3.1), showed a significant decrease in BMI z-scores in both genders (-0.09 ± 0.04, p=0.039) compared with those in the control group with initial BMI z-score <
3.5 (n=17 out of 23, mean baseline age 14.1, mean baseline BMI 31.6, mean baseline BMI z-score
3.01). No difference was found in adolescents with BMI z-scores >3.5.
In conclusion, this study indicates that adolescents with BMI z-scores < 3.5 may be successfully treated in a clinical setting in group meetings, with only four sessions through a multidisciplinary team approach. Ninety percent completed the 1-year program based on a theoretical framework of family therapy and brief solution-focused therapy which is promising for the future implementation of the model.
III. The aim of this study was to assess self-esteem in a clinical sample of obese children and adolescents to better understand the natural development of self-esteem to be able choose appropriate ages and gender for treatment. Children and adolescents aged 8-19 years (n=107, mean age 13.2 years, mean BMI 32.5 (range 22.3 -50.6), mean BMI z-score 3.22 (range 2.19-4.79); 50 boys and 57 girls) were referred for treatment of primary obesity. Self-esteem was measured with a validated psychological test with 5 subscales: physical characteristics, talents and skills, psychological wellbeing, relations with the family, and relations with others. A linear mixed effect model used the factors gender and adolescence group, and the continuous covariates: BMI z-scores, and BMI for the parents as fixed effects and subjects as random effects. The results showed that age and gender, but neither the child’s BMI z-score, nor the BMI of the parents were significant covariates. Self-esteem decreased (p<0.01) with age on the global scale as well as on the subscales, and was below the normal level in both genders. Girls had significantly lower self-esteem on the global scale (p=0.04) and on

EASO Award Application, Attachment 3 Nowicka the two subscales physical characteristics (p<0.01) and psychological well-being (p<0.01).
3
In conclusion, we have found that self-esteem in a sample of extremely and morbidly obese children and adolescents referred for treatment is lower after the age of twelve, especially in girls. Special attention should be paid to adolescent girls and preventive actions to avoid psychological consequences in later life.
IV. The study was designed to investigate the possibility of reducing the degree of obesity in obese children by focusing on physical activity as an intervention. Seventy-six children (40 boys) aged 8-12 years (mean age 10.5 years, mean BMI 28.9, SD 3.0; mean BMI z-score 3.24, SD 0.49) were invited to participate in a one-week sports camp and six-month support system. After the camp a sports coach from a local sports club supported the child during participation in a chosen sport for six months.
Weight, height, body composition, and lifestyle were measured at baseline and after 12 months. Data were pooled from two camps, one with a self-selected control group and one randomized controlled trial, as there were no differences betweens camps. Twelve months after the camp the intervention group had a significant decrease in BMI z-score (baseline BMI z-score 3.22; follow up 3.10, p=0.023). The control group also reduced their BMI z-score (baseline BMI z-score 3.27; follow up
3.18, p=0.022). No differences were found in baseline values, follow-up values, or changes in BMI zscore between groups, nor between boys and girls.
In conclusion, this study shows that a one-week sports camp followed by six months of support by a local club did not significantly reduce BMI z-score or body composition, or improve lifestyle, compared with a waiting list control group.
V. The main aim of this paper was to provide a library of tools and techniques that a clinician in the field of obesity can use when working with families, in a multidisciplinary team or alone. In our treatment model evaluated in Paper I and II the goal is to provide families of children with obesity a medical and psychosocial support to match their level of need. To obtain that the team members act as experts in the medical assessment of the child within the context of possible changes created by the rest of the team. During the whole treatment the child’s health, growth and development is monitored by team members. This is communicated by the team during the first visit when the child is assessed, and the family gets feedback on the child’s health and lifestyle (food and physical activity) reported by the family during the initial diagnostic interview. When it comes to how the family should act to change the lifestyle, the therapists do not propose precise instructions, but instead influence the context of change. The impact of the influence is derived through three cornerstones of the program: approach, language and process. Each of these cornerstones is a result of employing a number of tools
(involving parents, intervene with questions, neutrality, adopting of a normalizing and nonblaming position, assuming motivation, highlighting exceptions to the problem, focusing on small changes, identifying resources in the family and creating positive climate by reframing). A number of challenges in adopting the model in different treatment settings are identified.
In conclusion, in this paper we have described that family based treatment of childhood obesity integrating family systems theory with evidence based medicine can be useful in a medical setting.
Interventions in pediatric obesity should include the family members, but also better use the family resources in the treatment.
General discussion
In this thesis we have shown that it is possible to treat severely obese children and adolescents with family therapy in a clinical setting. We also have shown that self-esteem is lower in girls and decreases after the age of twelve. Thus, special attention should be paid to adolescent girls. In addition we have shown that intervention focus on physical activity did not reduce the degree of obesity in obese children. We have also described how techniques based on family therapy can be used in a clinical setting to strengthen resources in families with obese children and adolescents.

EASO Award Application, Attachment 3 Nowicka
Researchers have studied treatment of obese pediatric subjects (15). Because these were single studies, we tried to reproduce the psychological method used previously (18) in a clinical setting
(Paper I). In psychological treatment the number of sessions varies (21, 22). Family therapy interventions have shown beneficial effects on BMI with a limited number of sessions (18, 23). We have achieved such an effect with an average of only 3-4 sessions per family. This represents, to our knowledge, the fewest number yet published (21, 22). The low dropout rates in Paper I and II (19%
4 respectively 10%) are one of the lowest that have been documented in the treatment of pediatric subjects (15). The limited number of sessions and the use of a theoretical framework of family therapy and brief solution-focused therapy might be one possible explanation for the high completion rate. The use of such a model may support the therapist in communicating with the family thus making the study outcome including the completion rate less dependent on social skills and clinical experience of study personnel.
In Paper II we have found that the degree of obesity may affect treatment outcome in obese adolescents. The degree of childhood obesity is known to be a risk factor for adult obesity (24). Using epidemiological data, Freedman suggested the 99 th percentile of CDC growth charts (25) as an appropriate cut-off point to identify children and adolescents with severe obesity thus being at risk. It seems that adolescent obesity above a BMI z-score of 3.5 (26) or 99 th percentile, defined as severe, extreme, or morbid, is a challenge for clinicians. It is likely that those adolescents with BMI z-scores
> 3.5 could be treated with better results with the single family sessions (18, 23).
When examining factors influencing self-esteem in obese pediatric subjects referred to our obesity outpatient clinic (Paper III) we have found that self-esteem was below the normal level at higher ages.
In addition, girls had significantly lower self-esteem on the global scale and on the two subscales
Physical Characteristics and Psychological Well-Being. The results of this study have many clinical implications. Firstly, as self-esteem is worse in adolescence and especially in girls, it is crucial to increase awareness of potentially susceptible subgroups in clinical populations. Secondly, where relations with family are well, especially in younger children (significantly higher in younger boys compared with the reference material), parents should be regarded as an important resource in treatment. Finally, since self-esteem deteriorates at higher ages, treatment of adolescent obesity should include elements designed to enhance and protect their self-esteem (27).
We have also found in the first controlled longitudinal study (Paper IV) that a one-week sports camp followed by six months of support by a local club did not result in additional reduction of BMI zscore or body composition, or improved lifestyle, when compared with a waiting list control group, as these also reduced BMI z-scores. These results are novel and contrary to previous research that has shown positive results of weight-loss camps on body composition and psychosocial well-being in short-term and nonrandomized studies (28-33). It can be speculated whether the role of coaches should be expanded to include more intensive contact with the families. Most of the children and their parents were satisfied with the support system, though parents less so. This might be due to the limited focus on parental involvement in the intervention design, which may have resulted in inadequate use of parental resources.
More research is needed on how to teach new strategies and apply family based methods in a clinical setting. Furthermore it is needed to improve physical activity and self-esteem in the management of childhood obesity. A future strategy might include the Family Weight School for BMI z-score below
3.5 as a first step and single family therapy for younger children and these who have BMI z-score above 3.5. Treatment should start at the lower age and special attention should be given to girls.
References
1. Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, 2003-
2.
3.
4.
2006. Jama 2008;299(20):2401-5.
Sundblom E, Petzold M, Rasmussen F, Callmer E, Lissner L. Childhood overweight and obesity prevalences levelling off in Stockholm but socioeconomic differences persist. Int J Obes (Lond) 2008;32(10):1525-30.
Sjoberg A, Lissner L, Albertsson-Wikland K, Marild S. Recent anthropometric trends among Swedish school children: evidence for decreasing prevalence of overweight in girls. Acta Paediatr 2008;97(1):118-23.
Neovius M, Janson A, Rössner S. Prevalence of obesity in Sweden. Obes Rev 2006(7):1-3.

EASO Award Application, Attachment 3 Nowicka
5.
6.
Mossberg HO. 40-year follow-up of overweight children. Lancet 1989;2(8661):491-493.
Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight
7.
8.
5 adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med 1992;327(19):1350-5.
Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. Social and economic consequences of overweight in adolescence and young adulthood. N Engl J Med 1993;329:1008-1012.
Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
JAMA 2003;289(14):1813-9.
Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Allen K, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med 2002;11(802-10).
Weiss R, Dufour S, Taksali SE, Tamborlane WV, Petersen KF, Bonadonna RC, et al. Prediabetes in obese youth: a syndrome of impaired glucose tolerance, severe insulin resistance, and altered myocellular and abdominal fat partitioning. Lancet 2003;362(9388):951-7.
Brambilla P, Lissau I, Flodmark CE, Moreno LA, Widhalm K, Wabitsch M, et al. Metabolic risk-factor clustering estimation in children: to draw a line across pediatric metabolic syndrome. Int J Obes (Lond) 2007;31(4):591-600.
Baker JL, Olsen LW, Sorensen TI. Childhood body-mass index and the risk of coronary heart disease in adulthood.
N Engl J Med 2007;357(23):2329-37.
Flodmark CE, Lissau I, Moreno LA, Pietrobelli A, Widhalm K. New insights into the field of children and adolescents' obesity: the European perspective. Int J Obes Relat Metab Disord 2004;28(10):1189-96.
Flodmark CE, Marcus C, Britton M. Interventions to prevent obesity in children and adolescents: a systematic literature review. Int J Obes 2006;30:579-589.
Summerbell C, Ashton V, Campbell K, Edmunds L, Kelly S, Waters E. Interventions for treating obesity in children. In: Cochrane Review. Chichester, UK: John Wiley & Sons, Ltd; 2004.
Braet C, Van Winckel M. Long-term follow-up of a cognitive-behavioural treatment program for obese children.
Behav Ther 2000;31:55-74.
Epstein L, Valoski A, Wing R, McCurley J. Ten year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol 1994;13:373-383.
Flodmark CE, Ohlsson T, Ryden O, Sveger T. Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy. Pediatrics 1993;91(5):880-4.
Edwards C, Nicholls D, Croker H, Van Zyl S, Viner R, Wardle J. Family-based behavioural treatment of obesity: acceptability and effectiveness in the UK. Eur J Clin Nutr 2006;60:587-592.
Rudolf MCJ, Christie D, McElhone S, Sahota P, Dixey R, Walker J, et al. WATCH IT: a community based programme for obese children and adolescents. Arch Dis Child 2006;91:736-739.
Kitzmann KM, Beech BM. Family-based interventions for pediatric obesity: methodological and conceptual challenges from family psychology. J Fam Psychol 2006;20(2):175-189.
Young KM, Northern JJ, Lister KM, Drummond JA, O'Brien WH. A meta-analysis of family-behavioral weightloss treatment in children. Clinical Psychology Review 2007;27:240-249.
Nowicka P, Pietrobelli A, Flodmark CE. Low intensity family therapy intervention is useful in a clinical setting to treat obese and extremely obese children. Int J Pediatr Obes 2007;2(4):211-217.
Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr 2007;150(1):12-17.
CDC National Center for Health Statistics. 2000 CDC Growth Charts: United States. Percentile data files with
LMS values. 2000 [cited 2007; Available from: http://www.cdc.gov/growthcharts/
Daley A, Copeland RJ, Wright NP, Roalfe A, Wales JKH. Exercise therapy as a treatment for psychopathologic conditions in obese and morbidly obese adolescents: a randomized, controlled trial. Pediatrics 2006;118(5):2126-
2134.
Wardle J. The impact of obesity on psychological well-being. Best Practice & Research Clinical Endocrinology &
Metabolism 2005;19(3):421-440.
Southam MA, Kirkley BG, Murchison A, Berkowitz RI. A summer day camp approach to adolescent weight loss.
Adolescence 1984;19(76):855-68.
Brandt G, Maschhoff T, Chandler NS. A residential camp experience as an approach to adolescent weight management. Adolescence 1980;15(60):807-22.
Gately PJ, Cooke CB, Barth JH, Bewick BM, Radley D, Hill AJ. Children's residential weight-loss programs can work: a prospective cohort study of short-term outcomes for overweight and obese children. Pediatrics
2005;116(1):73-7.
Gately PJ, Cooke CB, Butterly RJ, Mackreth P, Carroll S. The effects of a children's summer camp programme on weight loss, with a 10 month follow-up. Int J Obes Relat Metab Disord 2000;24(11):1445-52.
Walker LL, Gately PJ, Bewick BM, Hill AJ. Children's weight-loss camps: psychological benefit or jeopardy? Int J
Obes Relat Metab Disord 2003;27(6):748-54.
Di Pietro M, Campanaro P, D'Angelo G, Di Ferdinando C, Pomilio M, Verrotti A, et al. Role of camping in the treatment of childhood obesity. Acta Biomed 2004;75(2):118-21.