International Journal of Medicine

and Pharmaceutical Science (IJMPS)

ISSN(P): 2250-0049; ISSN(E): 2321-0095
Vol. 6, Issue 3, Jun 2016, 21-28
TJPRC Pvt. Ltd.

A STUDY OF CHILDHOOD AND ADOLESCENT OBESITY WITH SPECIAL

REFERENCE TO EFFECT OF A COMBINED INTERVENTION THERAPY
G. N. DWIVEDI1, MANOJ UPADHYAY2, AMBRISH GUPTA3 & PRASHANT TRIPATHI4
1
2

Department of Pediatrics, G. S. V. M. Medical College & Associated Hospitals, Kanpur, Uttar Pradesh, India

Department of Anaesthesiology, G. S. V. M. Medical College & Associated Hospitals, Kanpur, Uttar Pradesh, India
3

Department of Pharmacology, G. S. V. M. Medical College & Associated Hospitals, Kanpur, Uttar Pradesh, India

Department of Biochemistry, G. S. V. M. Medical College & Associated Hospitals, Kanpur, Uttar Pradesh, India

ABSTRACT
Objective: To compare the effects of a combined nutritional-behavioral-exercise intervention therapy on
anthropometric measurements, fitness level and carotid intima media thickness in overweight/obese children and
adolescents.
Design: Longitudinal follow up study.
Setting: Children attending OPD in department of pediatrics, LLR & Associated Hospitals and School Camps

Method: 124 obese children aged 6-18 years were enrolled from OPD and schools. These children were
equally divided (62 each) into intervention (cases) versus control group. All cases were given combined nutritionalbehavioral-exercise intervention therapy for 3 months. After therapy these children were examined at 3 months and
again after completion of 12 months. During period of 3 months to 12 months, no further active intervention was
provided to cases. These children were compared with age and gender matched obese children, who did not participate

Original Article

from Kanpur city.

in intervention study and served as control. All characteristics of cases and controls were noted before intervention, at 3
months and after 12 months of follow-up and compared by t-test. Additionally, in this study 125 normal children (Not
obese or overweight) were also included for cross-sectional analysis of their intima media thickness with overweight and
obese children of this study to compare the effect of obesity on vascular system.
Results: On statistical analysis after 12 months in cases, body weight (+2.610.132 kg Vs +6.521.751 kg),
BMI (-0.41250.041 kg/m2 Vs +1.4730.9308 kg/m2), TSF (-1.2690.0957 cm Vs +2.0450.9138 cm), waist
circumference (-0.96150.1350 cm Vs +3.4091.716 cm), fitness level (+47.842.373 sec Vs -13.9344.160 sec) and
intima media thickness (-0.0210.0046 mm Vs +0.02380.025 mm) have shown the significant improvement (P< 0.05).
Although differences were also present after 3 months of intervention, body weight (+0.650.107 kg Vs +2.330.1165
kg), BMI (-0.0980.0101 kg/m2 Vs +0.68380.1452 kg/m2), triceps skinfold thickness (-0.65380.0064 cm Vs
+0.72721.6767 cm), waist circumference (-0.4900.3178 cm Vs +1.4090.06745 cm) and fitness level (+59.6156.2953
sec Vs -18.5683.91006 sec), but these results were not statistically significant (P> 0.05) except improvement in fitness
level which was statistically significant even after 3 months (P< 0.05).
Conclusion: This study demonstrates the long-term (12 months) beneficial effects of a combined
nutritional-behavioral-exercise intervention therapy for treatment of childhood obesity. Short-term (3 months) effects
may not be significant but long-term effects are encouraging. Weight loss should not be encouraged in every case of
obesity. Obesity is a risk factor for early atherosclerotic changes and these changes are reversible with weight control
measures.

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22

G. N. Dwivedi, Manoj Upadhyay,

Ambrish Gupta & Prashant Tripathi

KEYWORDS: Behavioral-Exercise Intervention, Long-Term Effects & Early Atherosclerotic Changes

Received: Apr 16, 2016; Accepted: May 06, 2016; Published: May 20, 2016; Paper Id.: IJMPSJUN201603

INTRODUCTION
Obesity appears to originate in childhood and track to adulthood. Obesity is less prominently associated with
morbidity in adolescence but is a strong precursor of obesity and related morbidity in adulthood. There are indications that
obesity in childhood or adolescence leads to persistent obesity in adulthood and the expected complications. Therefore,
from a public health perspective, it is important to monitor and control obesity in adolescence.
Evidence of an association between physical activity and weight gain remains sparse. Nevertheless, in an effort to
halt or reverse trends in obesity, promotion of physical activity in children and adolescents has been identified as a key
focus of efforts to promote health. Physical activity among children and adolescents is believed to be insufficient and low
levels of activity seem to persist into adulthood. The development and evaluation of interventions to promote physical
activity in young people is therefore a priority. Furthermore, physical activity for young people can contribute to the
enhancement of psychological and social well-being. The primary hypothesis is that the exercise therapy intervention
would lead to changes in participants' mental health and physical activity behaviour. By implication, these changes in
physical activity behaviour might also translate into reductions in participants' BMI scores at follow-up.
BMI is an indicator of overall adiposity; Whereas Waist Circumstances (WC) is advocated as an indicator of
abdominal fat content. In this study anthropometric measures (weight, height, BMI, WC, triceps skin fold thickness) and
non-invasive procedures like Carotid Color Doppler study for intima-media thickness along with Treadmill test for
assessment of fitness were used to compare the effects of a supervised combined intervention therapy in study versus
control group.
The International Obesity Task Force (IOTF) and US Center for Disease Control and Prevention (CDC)
have developed age and gender specific BMI.
IOTF BMI cut off points are: Overweight > 25 kg/m2
Obesity > 30 kg/m2
CDC cut off points are:
Overweight BMI from 85th to 94th percentile of age gender specific.
Obese BMI 95th percentile of age and gender specific.
Even with no generally accepted current international definitions for overweight and obesity in children, both the
Centers for Disease Control and Prevention and the European Childhood Obesity Group have recommended the use of BMI
both for clinical work and for epidemiologic research.

SUBJECTS AND METHODS

Study Population
This study was a longitudinal follow-up study of overweight and obese children and adolescents of 6-18 years of
age from Kanpur city. The study was conducted at the department of Pediatrics, G.S.V.M. Medical College and L.L.R. &
Impact Factor (JCC): 5.4638

NAAS Rating: 3.54

A Study of Childhood and Adolescent Obesity with Special

Reference to Effect of a Combined Intervention Therapy

23

associated Hospitals, Kanpur from December 2008 to July 2010. Cases were selected from Public Schools of Kanpur City
through School health program camps and from children attending Out Patients Department (O.P.D.) in L.L.R. and
associated hospitals.

INTERVENTION DESIGN
In this study informed consent was taken from parents of 147 children and out of them 23 children did not satisfy
the inclusion criteria, so these children were excluded. Study was started with 124 children of age group 6-18 years. These
children were divided into intervention (cases) versus control group (62 in each group). Out of these 124 children, only 118
children could be examined after 3 months and 96 children (52 cases and 44 controls) completed the follow-up after 12
months. So these 96 children were included for final statistical analysis at 3 months (short term) and after 12 months (long
term). Rest 28 children were lost to follow-up (10 cases and 18 controls), so these were excluded from statistical analysis.
Before starting intervention, all baseline characteristics i.e. age and sex composition, weight, height, BMI, waist
circumference, triceps skin fold thickness, parental obesity, eating habits, fitness level, carotid intima media thickness and
habitual activity of cases and controls were noted. On comparison there was no significant difference in all baseline
characteristics of case and control group.
All cases were given combined nutritional-behavioral-exercise intervention therapy for 3 months. After therapy
these children were examined at 3 months and again followed-up after completion of 12 months. During period of 3
months to 12 months, no further active intervention was provided to cases. These children were compared with obese
children, who did not participate in intervention study and served as control. Controls were also followed-up after 3 months
and again after 12 months. All characteristics of cases and controls were noted before intervention, at 3 months and after
12 months of follow-up and compared by t-test.
Additionally, in this study 125 normal children (Not obese or overweight, i.e. BMI <85th percentile) were also
included for cross-sectional analysis of their intima media thickness with baseline (before intervention) carotid intimamedia thickness of 124 overweight and obese children (BMI >85th percentile) of this study to compare the effect of obesity
on vascular system.

RESULTS
This study was performed to study the effects of a supervised combined nutritional-behavioral-exercise
intervention therapy on anthropometric measurements (Weight, Height, BMI, WC, TSF), fitness level and carotid intima
media thickness in intervention group (cases) versus control group.
In this study out of 52 cases, 32 (61.53 %) were male and 20 (38.47 %) were female while out of 44 controls, 25
(56.81 %) were male and 19 (43.19 %) were female. Out of 57 males, 33 (57.89 %) were obese and 24 (42.11 %) were
overweight, while out of 39 females, 18 (46.15 %) were obese and 21 (53.85 %) were overweight.

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24

G. N. Dwivedi, Manoj Upadhyay,

Ambrish Gupta & Prashant Tripathi

Table 1: Characteristics of Study Participants before Intervention (N=96)

Age (years)
Gender (male/female)
Weight (kg)
Height (meters)
BMI (kg/m2)
Waist circumference
(cm.)
Triceps skinfold thickness
(cm.)
Intima Media Thickness
(mm.)
Endurance Time (sec.)
Parental Obesity (Yes/No)

Intervention Subjects
(n = 52)
9.902.436
32/20
49.0813.447
144.3014.499
23.132.538

Control Subjects
(n = 44)
10.382.365
25/19
51.1413.419
147.0913.515
23.182.662

84.469.264

85.159.531

24.304.085

24.594.556

0.5770.04582

0.56250.03907

912.6591.19
12/40

917.8168.91
11/33

This table is showing comparison of baseline (before intervention) characteristics of study participants. No
significant differences (p>0.05) were present between both groups before the intervention.
Table 2: Comparison of Intervention Group after 12 Months (N=52)

49.0813.447
144.3014.499
23.132.538

After 3
months
(n = 52)
49.7413.340
145.7114.477
23.032.548

After 12
months
(n = 52)
51.7013.315
149.5714.235
22.722.579

84.469.264

83.978.946

83.59.399

24.304.085

23.654.092

23.043.990

0.5770.04582

0.5560.05052

912.6591.19

972.2697.488

960.593.566

Before intervention
(n = 52)
Weight (kg)
Height (meters)
BMI (kg/m2)
Waist circumference
(cm.)
Triceps skinfold
thickness (mm.)
Intima Media
Thickness
(mm.)
Endurance Time
(sec.)

Table 3: Comparison of Control Group after 12 Months (N=44)

Weight (kg)
Height (meters)
BMI (kg/m2)
Waist circumference
(cm.)
Triceps skinfold
thickness
(mm.)
Intima Media Thickness
(mm.)
Endurance Time
(sec.)

Impact Factor (JCC): 5.4638

Before Intervention
(n = 44)
51.1413.419
147.0913.515
23.182.662

After 3 Months
(n = 44)
53.3813.302
148.513.574
23.862.517

After 12 Months
(n=44)
57.6713.295
152.1513.660
24.652.321

85.159.531

86.569.463

88.569.754

24.594.556

25.314.724

26.644.621

0.56250.03907

0.58600.03119

917.8168.915

899.2565.005

903.8873.990

NAAS Rating: 3.54

A Study of Childhood and Adolescent Obesity with Special

Reference to Effect of a Combined Intervention Therapy

25

Table 4: Comparison of Non-Obese Population (N=125) With Obese Study Participants (N =124)

Age (years)
Gender
(male/female)
Weight (kg)
Height (meters)
2

BMI (kg/m )
Intima Media
Thickness
(mm.)

Non-Obese
Children
(n = 125)
9.9763.207

Obese
Children
(n = 124)
9.9112.426

69/56

74/50

>0.05

49.2913.537

<0.05

144.7314.378

>0.05

23.042.519

<0.05

0.57130.04471

<0.05

35.20411.67
4
143.0316.86
2
16.681.813
0.50440.048
37

P Value
>0.05

This table is demonstrating that there is no significant difference between non-obese children and
obese/overweight children of this study in age and sex composition (P>0.05) but significant difference in carotid intimamedia thickness (P<0.05) is evident, which is due to differences in their weight and BMI. Mean carotid intima-media
thickness is much lower in non-obese children as compared to obese/overweight children of this study.

DISCUSSIONS
Our intervention was associated with significant (P<0.05) weight control, reduced BMI, reduced body fat,
improved fitness as well as reduced carotid intima media thickness among obese children of intervention group after 12
months of follow-up. In contrast, obese children who did not participate in the intervention program gained weight much
more rapidly than intervention group, increased BMI and body fat, reduced fitness and increased carotid intima media
thickness. On statistical analysis body weight (+2.610.132 kg Vs +6.521.751 kg), BMI (-0.41250.041 kg/m2 Vs
+1.4730.9308 kg/m2), TSF (-1.2690.0957 cm Vs +2.0450.9138 cm), WC (-0.96150.1350 cm Vs +3.4091.716 cm),
fitness level (+47.842.373 sec Vs -13.9344.160 sec) and CIMT (-0.0210.0046 mm Vs +0.02380.025 mm) have
shown the significant improvement (P< 0.05) in intervention group after 12 months.
Although differences were also present after 3 months of intervention, i.e. body weight (+0.650.107 kg Vs
+2.330.1165 kg), BMI (-0.0980.0101 kg/m2 Vs +0.68380.1452 kg/m2), TSF (-0.65380.0064 cm Vs +0.72721.6767
cm), WC (-0.4900.3178 cm Vs +1.4090.06745 cm) and fitness level (+59.6156.2953 sec Vs -18.5683.91006 sec), but
these results were not statistically significant (P>0.05) except improvement in fitness level which was statistically
significant even after 3 months (P< 0.05).
On comparison the long-term (12 months) outcomes of this intervention are almost similar to the findings of
Eliakim A et al (2004)3 and Dan Nemet et al (2005)4but the short-term (3 months) outcomes of our study are different
from findings of Dan Nemet et al (2005)4.The possible explanation of this differences is that as most of the participants of
our study were not suffering from severe obesity, weight loss was not the primary aim of this intervention.
Most of the cases and controls were having increment in their weight after 12 months of follow-up. The mean
increment in weight of intervention group (cases) was 2.5 Kg against mean increment of 6.5 Kg in control group after 12
months of follow-up. Out of 52 cases, 15 children did not show increment in their weight after 3 months, while only 5
children were not having increment in their weight after 12 months. It was because 10 children gained weight during 3 to

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G. N. Dwivedi, Manoj Upadhyay,

Ambrish Gupta & Prashant Tripathi

12 months period. Since the control group kept gaining weight during the observation period much more than intervention
group, it may be considered the positive effect of this intervention. Although intervention participants did not reduce their
weight but their mean BMI was reduced while it was increased in control group. Because BMI increases naturally with
age, maintenance of BMI, and in some cases even attenuation of the increase in BMI, should be considered a success.
Out of 52 obese/overweight children from intervention group in our study, 12 children (5 boys and 7 girls) were
not obese or overweight (BMI< 85th Percentile) after completion of study and 8 children (7 boys and 1 girl) were
reclassified as overweight (BMI of 85th to 95th percentile) from obese category (BMI >95th Percentile) after 12 months of
follow-up. Out of 12 children, 2 children (1 boy and 1 girl) were from obese and 10 children (4 boys and 6 girls) from
overweight category before study. Final BMI was decreased in intervention group.
In this study there was a significant difference (P<0.05) between carotid intima-media thickness of normal nonobese population versus thickness of overweight/obese children of study population before intervention, as well as between
intervention group (n=52) and control group (n=44) after 12 months of follow-up. The higher baseline carotid intimamedia thickness of all obese/overweight children of study (n=124) as compared to non-obese children (n=125) suggests
that obesity have an adverse effect on cardiovascular system. The decreased intima-media thickness in obese children with
weight control measures suggests the reversibility of early atherosclerotic changes. These findings are similar to the
findings of Raimer Wunsch et al (2006)2.
In our study endurance time noted in seconds with the help of Tread Mill Test (TMT), as a measure of fitness
level, was the only parameter to show the significant improvement after 3 months of intervention (P<0.05) and it continued
to remain the same even after 12 months in intervention group. The control group never showed the improvement in their
fitness level as compared to intervention group. These results are similar to findings of Dan Nemet et al (2005)4.
This study was started with 124 obese children, out of them 96 could be followed-up after 12 months. Rest 28
children were lost to follow-up. Most of the children, who were lost to follow-up, were recruited from out patient
department (O.P.D.), while most of the children who completed the study were recruited from public schools. The obese
children of the same class were the constant source of stimulation and encouragement for other children to continue their
participation in the study.
In Addition, the families who followed the same dietary and behavioural modification in support of their children
had better eventual outcome.

CONCLUSIONS
This study demonstrates the long-term (12 months) beneficial effects of a supervised combined nutritionalbehavioral-exercise intervention therapy for treatment of childhood obesity. Short-term (3 months) effects may not be
significant but long-term effects are encouraging. Weight loss should be encouraged only in severe obesity, whereas
maintenance of body weight with continued linear growth, accompanied by development of a healthier lifestyle, should be
the goal for the majority of obese children. Moreover, because BMI increases naturally with age, maintenance of BMI, and
in some cases even attenuation of the increase in BMI, should be considered a success and this was one of the most
important observation of our study.

Impact Factor (JCC): 5.4638

NAAS Rating: 3.54

A Study of Childhood and Adolescent Obesity with Special

Reference to Effect of a Combined Intervention Therapy

27

KEY MESSAGE
1.

When evaluating the results during such intervention therapy, the outcome as a short-term gain may not be
apparent initially, but long-term effects are encouraging.

2.

Weight loss should not be encouraged in every case of obesity. Maintenance of body weight with continued linear
growth, accompanied by development of a healthier lifestyle should be the goal for the majority of obese children
and should be considered a success of such intervention therapy.

3.

Obesity is a risk factor for early atherosclerotic changes and these changes are reversible with weight control
measures.

4.

Initial improvement in physical fitness even without weight loss can be used as an incentive for encouragement of
participants to continue participation in such intervention therapy.

REFERENCES
1.

Cole TJ, Bellizzi MC, Dietz WH, Flegal KM: Establishing a standard definition for child overweight and obesity world-wide.
International Survey MBJ. 2000; 320: 1240-3.

2.

Raimer Wunsch, Gideon de Sousa, Ander Michael Tosohke, Thomas Reinehr : Intima-media thickness in obese children before
and after weight loss. Paediatrics 2006; 118(6): 2334-2340.

3.

Eliakim A, Friedland O, Kown G, Wolach B, Nemet D: Parental obesity and higher pre-intervention BMI reduce the likelihood
of a multidisciplinary childhood obesity program to succeed a clinical observation. J Pediatr Endocrinol Metab 2004; 8:
1055-61.

4.

Dan Nemet, Sivan Barkan, Yoram Epstein, Orit Friedland, Galit Kowen, Alon Eliakim: Short and long term beneficial effects
of a combined Dietary-Behavioural-Physical activity intervention for the treatment of childhood obesity. Pediatrics 2005;
115(4): e443-e449.

5.

A Kablak Ziembicka, W Tracz, T Przewlocki, P Pieniazek, A Sokolowski,M Konieczynska : Association of increased carotid
intima-media thickness with the extent of coronary artery disease. Heart 2004; 90:1286-1290.

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Epstein LH, Valoski AM, Kalarchian MA, McCurley J: Do children lose and maintain weight easier than adults. Obes Res
1995; 3(5): 411-7.

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Esther MF van Sluijs, Alison M McMinn, Simon J Griffin: Effectiveness of intervention to promote physical activity in children
and adolescents: systematic review of controlled trials. BMJ 2007; 335 (7622): 703.

8.

Evelyn P Whitlock, Elizabeth A O'Conner, Selvi B Williams, Tracy L Beil: Effectiveness of Primary Care Interventions for
Weight Management in Children and Adolescents. Agency for Healthcare Research and Quality (US); January 2010.

9.

Margarita D Tsiros, Natalie Sinn, Alison M Coates, Peter R C Howe, Jonathan D Buckley: Treatment of adolescent
overweight and obesity. European Journal of Pediatrics 2008; 167 (1): 9-16.

10. Michael M. Ross, Joseph A. Skelton, Stacy Kolbash, Gail M. Cohen: Multidisciplinary Treatment of Pediatric Obesity:
Nutrition Evaluation and management. Nutrition in Clinical Practice 2010; 25: 327-334.
11. Michiel L. Bots, Gregory W. Evans, Ward A. Riley, Diederick E. Grobbee : Carotid Intima-Media Thickness Measurements in
Intervention Studies. Stroke. 2003; 34:2985.
12. Rebecca A Meriwether, Felipe Lobelo, Russell R Pate: Themed Review: Clinical Interventions to Promote Physical Activity in

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G. N. Dwivedi, Manoj Upadhyay,

Ambrish Gupta & Prashant Tripathi
Youth. Am J Lifestyle Med. 2008; 2(1):7-25.
13. SS Guo, AF Roche, WC Chumlea, JD Gardner , RM Siervogel : The predictive value of childhood body mass index values for
overweight at age 35 yrs. American Journal of Clinical Nutrition 1994; Vol 59, 810-819.
14. Yael Latzer, Laurel Edmunds, Silvana Fenig, Moria Golan, Eitan Gur: Managing Childhood Overweight: Behavior, Family,
Pharmacology, and Bariatric Surgery Interventions. Obesity 2009; 17(3): 411423.

APPENDICES
Background: Obesity has become the most common pediatric chronic disease in the modern era. Early prevention
and treatment of childhood and adolescent obesity is mandated. Surprisingly, however, only a minor fraction of obese
children participate in weight reduction interventions, and the longer-term effects of these weight-reduction interventions
among children have not been elucidated.
Objective: To examine prospectively the short- and long-term effects of a 3-month, combined dietary-behavioralphysical activity intervention on anthropometric measures, body composition, dietary and leisure-time habits, fitness, and
lipid profiles among obese children.
Methods: In this randomized prospective study, 24 obese subjects completed the 3-month intervention and were
compared with 22 obese, age- and gender-matched, control subjects.
Results: At 3 significant months, there were differences in changes in body weight (2.8 2.3 kg vs 1.2 2.2 kg),
BMI (1.7 1.1 kg/m2 vs 0.2 1.0 kg/m2), body fat percentage (from skinfold tests; 3.3 2.6% vs 1.4 4.7%), serum
total cholesterol level (24.6 15.1 mg/dL vs 0.8 18.7 mg/dL), low-density lipoprotein cholesterol level (23.3 15.2
mg/dL vs 3.7 17.3 mg/dL), and fitness (215 107 seconds vs 50 116 seconds) in the intervention group versus the
control group. After a 1-year follow-up period, there were significant differences between the intervention group (n = 20)
and the control group (n = 20) in body weight (0.6 6.0 kg vs 5.3 2.7 kg), BMI (1.7 2.3 kg/m2 vs 0.6 0.9 kg/m2),
and body fat percentage. There was a significant increase in leisure-time physical activity among the intervention
participants, compared with a decrease among the control subjects.
Conclusions: Our data demonstrate the short- and longer-term beneficial effects of a combined dietary-behavioralphysical activity intervention among obese children. These results highlight the importance of multidisciplinary programs
for the treatment of childhood obesity and emphasize their encouraging long-term effects.

Impact Factor (JCC): 5.4638

NAAS Rating: 3.54