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УДК 616-05.2
WAYS OF IMPROVING OF MEDICAL AND PSYCHOLOGICAL REHABILITATION OF CHILDREN WITH CONSTITUTIONAL-EXOGENOUS OBESITY IN HOSPITAL AND SANATORIUM E.I.Roytman, A.B.Ershevskaya, L.N.Pogrebnyak
Yaroslav-the-Wise Novgorod State University, [email protected]
We studied immediate and long-term effectiveness of integrated medical and psychological rehabilitation of children with constitutional-exogenous obesity (CEO) during the program «School of overweight child» in hospital and sanatorium according to the following parameters: body mass, percentage of fat mass (PFM), psychological changes, eating behavior and physical activity. Keywords: obesity, children, medical and psychological rehabilitation, sanatorium, hospital
Изучены непосредственная и долгосрочная эффективность комплексной медико-психологической реабилитации детей с конституционально-экзогенным ожирением (КЭО) по программе «Школа ребенка с лишним весом» в условиях стационара и санатория по следующим параметрам: масса тела, процент жировой массы (ПМ), психологические изменения, пищевое поведение, двигательная активность.
Ключевые слова: ожирение, дети, медико-психологическая реабилитация, санаторий, стационар
Introduction
Obesity in children and adolescents is one of the urgent problems of modern health care due to the prevalence of this disease and the possible consequences in the future [1,2].
According to most researchers in 60-85% of adults the obesity manifests in children's age [3,4]. Almost in all regions of the world's number of such children has been steadily increasing and doubling every three decades [5]. Currently in the developed countries of the world 25% of adolescents are overweight [6,7]. In the Russian Federation on the current data 8-12% of children are obese, whereas in the early 1960 obesity was noted in only 4-5% of school children [3].
Despite the importance of obesity in children and adolescents currently there are no effective methods of treatment available for this disease. While improving the effectiveness of rehabilitation programs new approaches, implementation of modern methods and practices of schools of motivational training of patients have been proposed, but the solution of problem of consolidation and achieving of long-term therapeutic effects are currently topical [8,9]. The need of long-term effectiveness of treatment of obesity in children has prompted us to search for new organizational rehabilitation program.
For the first time in Russia on the basis of the Novgorod Regional Children's Hospital since 2000 we introduced a program of rehabilitation «School for overweight child» for overweight children with CEO, since 2006 - in sanatorium of Novgorod Reigion «Mother and Child» («Sosnovka»).
In the development of obesity from children significant role belongs to a combination of factors: genetic, exogenous, cerebral, pubertal and psychological, so disease control is possible only through a long and complex impact of the rehabilitation program [10]. In addition, the modern concept of rehabilitation is based on a set of interrelated components (medical, psychological, social) that form a dynamic system, effect of which is directed to
achieving the ultimate goal [11]. Responding to current requirements of rehabilitology, the process of rehabilitation in program «School for overweight child» is represented by united medical, psychological, educational complex, including long-term effects of therapeutic measures, the principles of the system family and cognitive-behavioral psychotherapy. Microsocial surrounding of the patient is involved in the program, all the medical and rehabilitative measures are mediated through the personality of the child and focusing not only on the elimination of the disease, but also on the development of patient characteristics that will help in the future to adapt to the social environment.
The purpose of this research is to assess the immediate and long-term effectiveness of medical and psychological rehabilitation of children with CEO on the program “School for overweight children” realized on the basis of the hospital and sanatorium.
Materials and methods
We investigated 126 children with CEO of I-III degree in age from 7 to 17 years, 88% of patients with obesity had secondary diencephalon syndrome. All children were divided into three groups: I group included 46 children that have already passed program of «School» in Novgorod Regional Children's Hospital, 16 boys and 30 girls. Group II consisted of 50 children (22 boys and 28 girls), rehabilitated under the program «School» in the sanatorium of Novgorod Region «Mother and Child». Group III (control group) included 30 obese children who did not receive treatment and have not undergone rehabilitation program «School».
We used the methods of clinical examination, including anthropometry, calipometry, the definition of PFM and others. To assess eating behaviour we used food diary, physical activity — the questionnaire «Physical activity», for psychodiagnostics — Eysenck and Spiel-berger-Hanin tests. To investigate the child's personality and his interpersonal relationships we used projective techniques: drawings, «I am now», «I am by the eyes of
others», «What I want to be», «My family»; for a psychological examination of the child's family — «Family so-ciogram» (E.G.Eidemiller, O.V.Cheremsin 1990) and questionnaire for parents «Analysis of family relation-ships» (E.G.Eidemiller, V.Justickis 1990).
The main objectives of the rehabilitation program in «School» were: forming of rational lifestyle for the whole family, the rationalization of nutrition and increasing physical activity of child, creating motivation for treatment, self-management education, and adequate treatment of disease-satellites. Teaching of children of I and II groups has been carried out in the direction of modification of eating behavior and physical activity, creating motivation for weight loss, solving of problem of mental and emotional stress. In addition, we actively drew attraction of child’s family to the process of rehabilitation. For children of I group and their parents the duration of rehabilitation ranged from 7 to 10 days and included training program in the form of 8 lessons, containing recent data on obesity, from 1.5 to 2 hours each one. Children microgroups consisted of 2-4 children of the same age. In the sanatorium group (II group) a program of rehabilitation was 21 days, the theoretical materials were supplemented by visual ones and practical skills of weighing, calculating of body mass index, waist circumference / hip circumference, determining of the obesity degree, daily calculating of calorie. We used the methods of group therapy, role playing, discussions and autogenic training in working with children. Work with parents was conducted at the beginning, at the end of sanatorium session basing on principle «parent training», the basic concept which derives from behavioral therapy.
In the process of rehabilitation all children were prescribed hypocaloric diet by Knyazev Y.A. [12]. Group
II after at discharge from the sanatorium were recommended low-fat diet by Ginsburg M.M. [1] for the effect of weight maintenance and further its reducing. Along with the diet rehabilitation program included physical activity, the expansion of which was carried out by medical and morning exercises. It is important to note that the natural conditions of sanatorium allowed to greatly diversify the physical activity of children of II group due dosed walking, outdoor games, gym and swimming pool.
Both in hospital and in sanatorium rehabilitation program included treatment of disease-satellites. Taking into account the adverse effects of inflammatory diseases of the nasopharynx on the function of the hypothalamic-pituitary system we performed sanitation of foci of infection with the use of drugs «Tonzilgon», «Hofitol» in obese children in case of chronic tonsillitis, sinusitis and pharyngitis. Children with constitutional exogenous obesity, complicated by secondary diencephalic syndrome we carried out treatment with anti-inflammatory, absorbable, desensitizing, vascular, and nootropic drugs in accordance with the recommendations of neurologist, cardiologist. As antihypertensive drugs ACE — inhibitors were used under daily control of blood pressure in the morning and evening. During the whole time rehabilitation all children received multivitamin complexes with microelements, iodine preparations; children over 12 years old — Ca D3 Nycomed Forte in age dosage and enzymes if necessary.
Because of the short-term treatment in hospital performance assessment of the immediate rehabilitation of children in group I was not reasonable. Dynamic observation at 3, 6-9, and 12 months in I group was performed in 36 children. In II group the immediate results of rehabilitation were assessed in all 50 children; 43, 46 and 39 children were examined in 3, 6-9 and 12 months respectively. Children of the comparison group (III) were examined in a year in dynamics. To assess the effectiveness of medical and psychological rehabilitation in each group we analyzed: body weight, percentage of fat mass, eating behavior, physical activity and psychological changes.
Results and discussion
In I group after a year of follow up 45.7% of children had positive dynamics in body mass (decrease in weight or it stayed unchanged). Immediately after the rehabilitation the positive dynamics was observed in all 50 children of II group. Average weight of the children surveyed in sanatorium was 77.06 ± 3.14 kg initially and 72.38 ± 2.89 kg after treatment (p < 0.05). In 3, 6-9, and
12 months significant decline compared with baseline data remained (70.49 ± 2.42 kg; 71.13 ± 2.39 kg and 72.88 ± 2.64 kg, respectively). In the comparison group after a year average body weight significantly increased (from 79.71 ± 3.85 kg up to 84.86 ± 3.96 kg).
In I group a year after rehabilitation 79.9% of children had positive dynamics PFM (20.02 ± 3.90% before treatment and 18.37 ± 3.00% after, p > 0.05). It is noteworthy that 100% of children of II group had significant decrease of PFM from 31.55 ± 1.42% to 26.01 ±
0.71% (p < 0.05) at the beginning and end of rehabilitation, respectively. A year after the rehabilitation average PFM in children of II group was 28.39 ± 1.32% (the differences are significant when compared with baseline PFM, p < 0.05). In the comparison group in a year average PFM significantly increased (from 32.10 ± 1.93% to 39.13 ± 1.72%).
As a result of training in program «School» eating behavior of children has changed. In I group one year after treatment in 78.26% of children consumption of sweets and bakery products significantly decreased, amount of fruits, vegetables and foods rich in protein increased (p < 0.01). In group II in 98% of children protein foods, fruits and vegetables were dominating immediately after recovery. A year after the rehabilitation the principles of good nutrition in this group were maintained in more than 50% of the children, 25.6% of children followed low-fat diet. In the control group the percentage of children who prefer fat food (93.3%), sweets (46.6%) and bakery products (50.0%) remained virtually unchanged during the year.
In the rehabilitated children regime of physical activity has changed. Initially more than half of children with obesity were physically inactive (78.26% in I group, 56.0% in II group). After rehabilitation both in I and II group children significantly increased the percentage of physical activity: lack of exercise was observed only in 21.74% and 38.4% of children respectively. In III group after a year of observation positive changes in physical activity were not observed: at the first examination physi-
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cal inactivity was found in 56.6% of children, in a year -in 63.3%.
As a result of psychological correction in psychological status of the rehabilitated children positive changes were highlighted. In I group I initially 39.13% of children had low self-esteem, a year low self-esteem was maintained in 26.08% of adolescents, the differences were significant (p < 0.05). The percentage of children with introverted personality orientation (from 34.78% initially to 19.56% after one year (p < 0.05)) and the level of neuroti-cism (from 36.95% to 32.6%) significantly decreased.
In II group at the end of sanatorium session trend toward lower percent of children with low self-esteem (from 46% to 38%) began to appear, the percentage of children with introverted personality orientation significantly decreased (from 62% to 44%); and the percentage of patients who were dissatisfied with their appearance significantly increased from 40% to 58% that in combination with increased self-esteem indicates the appearance of motivation for treatment of obesity. During the first examination in this group the motivation to treat had 24% of children; some elements of self-control were carried out in 8%. Immediately after the rehabilitation the motivation for further treatment appeared in 72% of children, self-control - in 98% of adolescents.
Repeated psychological testing of children of II group show that the percentage of introversion and low self-esteem remained virtually unchanged (43.5% and 38.4%) in one year. Increasing of self-esteem of obese children was caused by decreasing of personal anxiety. High level of anxiety among the patients of II group at the beginning of treatment were revealed in 44%, at the end of sanatorium session — in 30%, the differences were significant (p < 0.05). After a year of rehabilitation in this group of children high levels of personal anxiety continued to significantly decline. In the comparison group (III) high level of personal anxiety was detected in 46.6% of children during the first examination, in a year it has remained virtually unchanged (50%), the percentage of introverts and those with low self-esteem tended to increase (from 50% to 60% and from 43.3% to 50%, respectively).
As a result of correction of disturbed family relations and the inclusion of families in the rehabilitation program 30% of the patients of II group received psychological support from their parents. These children have noted that the active involvement of parents in the course of medical recommendations at home became for them incentive to self-control and was fundamental to creating and maintaining the motivation to further problem solving.
Thus, supervising children of I group we noted increase of self-esteem, reducing of introversion and neuroti-cism. Through modification of eating behavior and physical activity, there has been a clear downward trend in PFM in patients of both rehabilitation groups. Reduction of PFM in children of I and II groups was a gradual and long-term during the year of observation. In II group 21-day of sanatorium treatment and next year significantly the percentage of children with introverted personality orientation decreased, percentage of children dissatisfied with their appearance increased, which combined with a significant increase in self-esteem indicates the appearance of the children of motivation for treatment. After psychocorrec-
tion in this group high level of personal anxiety is diagnosed in less than a quarter of patients.
In the comparison group, in contrast, significant increase in average body weight and PFM were registered, as well as significant deterioration of the quality of life of children that reflected in psychological changes, the negative dynamics of eating behavior and physical activity.
Conclusions
1. The developed program of medical and psychological rehabilitation of children with CEO — «School for overweight children» can be used in pediatric practice as an organized and structured approach in the treatment of obesity in children, as it is effective, providing not only immediate but also long-term positive changes in physical, mental status of child and its relationship to family.
2. Medical and psychological rehabilitation of children with CEO in program «School for overweight children» in the hospital had a long-term positive impact on quality of life of patients by reducing body weight and PFM, raising self-esteem, decreasing neuroticism, as well as by rationalizing of lifestyle (modification of eating behavior, physical activity) and changing of microsocial surrounding of the child (including the family in the rehabilitation program).
3. Features of the second form of rehabilitation program «School for overweight children» are caused by its realization in sanatorium, medical and diagnostic facilities and environmental conditions which have allowed to diversify and efficiently combine medical and psychological methods of rehabilitation providing with longterm exposure (21 days) and integrated differential approach that contributed to the formation of optimal mental and physical condition of the child and caused longterm positive effect.
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