Wong, William W.*; Barlow, Sarah E.*; Mikhail, Carmen*; Wilson, Theresa A.*; Hernandez, Paula M.†; Shypailo, Roman J.*; Abrams, Stephanie H.*
*Department of Pediatrics, Baylor College of Medicine
†Texas Children's Hospital, Houston, TX.
Address correspondence and reprint requests to William W. Wong, PhD, USDA/ARS Children's Nutrition Research Center, 1100 Bates Street, Houston, TX 77030 (e-mail: email@example.com).
Received 29 May, 2012
Accepted 7 September, 2012
The project is partially supported by funds from the Houston Endowment and USDA/ARS grant #6250–51000–053.
The authors report no conflicts of interest.
ABSTRACT: In an earlier report, we showed that a 2-week, residential summer camp (Kamp K’aana) led to improved body weight, body mass index, body mass index z score, and self-esteem among obese children. To assess whether improvements in body weight and self-esteem translate into improvement in body fat and weight-related quality of life, we measured the changes in body fat by bioimpedance and quality of life by Impact of Weight on Quality of Life instrument on 42 multiethnic obese children who took part in our Kamp K’aana program. Significant reduction in body fat was detected with significant improvements in the weight-related quality of life scores.
The latest National Health and Nutrition Examination Survey 2007–2008 showed that approximately 19% of our children and adolescents were obese (body mass index [BMI] ≥95th percentile) (1). Childhood obesity is associated with increased risks of metabolic syndrome (2), type 2 diabetes mellitus (3), low self-esteem (4), and low quality of life (5). We reported earlier (6) that a 2-week residential summer camp program (Kamp K’aana) can lead to significant improvements in body weight, BMI z scores, and self-esteem. The present study assessed whether the reduction in body weight and improvement in self-esteem would translate into reduction in body fat and improvement in weight-related quality of life.
A total of 42 obese children (Table 1) between 9 and 14 years of age were enrolled in the Kamp K’aana program between August 1, 2010 and August 13, 2010 at Cho Yeh Camp, Livingston, TX. The cost of the camp was $1500 per camper with limited scholarships through in-kind donations available to underserved families. We received 31 applications and 21 children were selected for either partial or full scholarship. To participate in the program, the children had to be 9 to 14 years of age with a BMI ≥95th percentile for age and sex. The protocol was approved by the institutional review board for Human Subject Research for Baylor College of Medicine and affiliated hospitals. Written consent and assent were obtained from the parents and children, respectively, before enrollment in the study.
Dieticians at Texas Children's Hospital put together the Traffic Light diet menu and trained the camp kitchen staff in preparing the foods and serving the correct portions. A psychologist from Texas Children's Hospital or a master's degree–level counselor provided counseling. Daily lessons on healthy lifestyle (6) were provided by these volunteers as well as volunteer medical doctors. Body weights and heights were measured in duplicate at the beginning and again at the end of the 2-week program. Body composition was measured using a Tanita foot-to-foot bioimpedance instrument (Model TBF-410; Tanita Corporation of America, Arlington Heights, IL) at the beginning and again at the end of the 2-week program. Each child also completed an Impact of Weight on Quality of Life (IWQOL) questionnaire (7) at the beginning and at the end of the program.
Independent-sample t test was used to assess potential differences in age, baseline physical characteristics, and IWQOL scores by sex and ethnicity. Paired-sample t test was used to evaluate the changes in body weight, BMI, BMI z score, body fat, lean body mass (LBM), and quality of life scores at the end of the 2-week program. The program, WinPepi (http://www.brixtonhealth.com/pepi4windows.html), was used to compare the quality-of-life domain scores between our campers and those reported for normal-weight and obese children.
As shown in Table 1, all of the children were obese and consisted of 12 Hispanics, 17 whites, 12 African Americans, and 1 Asian with 17 boys and 25 girls. Many of the children have asthma (7), allergies (1), gastroesophageal reflux disease (1), attention deficit hyperactivity disorder (1), hypertension (2), acanthosis nigricans (2), diabetes mellitus (2), dyslipidemia (1), hypothyroidism (2), nonalcoholic steatohepatitis (1), and depression (4). Table 2 summarizes the total IWQOL scores and the scores of the 4 IWQOL domains of the campers before camp, after the 2-week camp, as well as the published scores for normal-weight and obese children (7). No significant differences were detected in any of the IWQOL scores among the 3 groups of children (P = 0.12) at baseline or between boys and girls (P = 0.67). Therefore, all of the children, regardless of sex and ethnicity, were pooled together to evaluate the effect of Kamp K’aana on body weight, body composition, and quality of life.
Significant reductions (Fig. 1) in body weight (−3.7 ± 1.6 kg, P < 0.001), BMI (−1.4 ± 0.6 kg/m2, P < 0.001), and body fat (−4.5 ± 3.0 kg or −3.5% ± 3.0%, P < 0.001) were observed at the end of the 2-week camp. The change in LBM was in the anticipated direction but was not significant (0.9 ± 3.5 kg, P = 0.13). The reduction in BMI z score (not shown) also was found to be significant (−0.09 ± 0.05, P < 0.001). One camper gained weight but the weight gain was accounted for by an increase in LBM with a reduction in body fat.
Table 2 shows that the baseline IWQOL scores of the Kamp K’aana campers were similar to those published for obese children (P = 0.32) but significantly lower (P < 0.001) than those published for normal-weight children with the exception for family relations. Significant improvements (Fig. 2) were detected in physical comfort (5.1 ± 12.1 units, P < 0.001), body esteem (10.9 ± 22.0 units, P = 0.004), social life (4.8 ± 13.2 units, P = 0.03), and the total IWQOL scores (5.9 ± 12.0 units, P = 0.004) after the 2-week camp. Change in family relations score was not significant (0.6 ± 7.5 unit, P = 0.60).
The reductions in body weight, BMI, and BMI z scores are similar to those observed in our earlier report (6) suggesting that the benefit of the Kamp K’aana program to reduce body weight is highly reproducible. Similar reductions in body weight, BMI, and BMI z score have been reported for obese children who attended a 6-week residential summer camp program in the United Kingdom (8). In a recent report, children attending a 4- to 8-week residential weight-loss camp also lost weight with reductions in BMI and BMI z score (9). The magnitude of the reduction was related to the length of attendance.
In the Kamp K’aana program, in addition to engaging the children in fun and confidence-building activities, the children also received nutrition lessons and healthy habits lessons so that they can acquire the knowledge and skills to make healthy food choices because introducing minority children to healthy food choices has been shown to modify their dietary habits (10).
There is concern that the reduction in body weight may represent a reduction in LBM rather than body fat. In the UK study (8), reduction in body weight was linked to a reduction in body fat (−5.6 kg or −3.0%), measured by air-displacement plethysmography, among obese children who attended a 6-week residential summer camp program. Using bioimpedance method, we measured a significant reduction in body fat (−4.5 ± 3.0 kg or −3.5% ± 3.0%, P < 0.001) among our obese campers. LBM was found to increase in our program (Fig. 1) but the increase was not significant, probably because of the small sample size. Because the 2 residential summer camp programs were carried out at 2 different continents and body fat was assessed using 2 different body composition methodologies, the beneficial effect of the residential summer camp program to reduce body fat among obese children is real and not an artifact. In our program, 1 child recovered from renal transplant gained weight but the gain was accounted for by an increase in LBM with a decrease in body fat. Otherwise, all the other children lost weight.
Although both the Kamp K’aana program (6) and the summer camp program in the United Kingdom (8) led to improvements in self-esteem, no study has been done to evaluate the effect of residential summer camp programs on weight-related quality of life. As shown in Figure 2, the IWQOL scores of our obese campers improved significantly following the 2-week program. The lack of change in the family relations score is not unexpected because the children were not with their families during the program.
The cost to attend the 2-week residential summer camp program was $1500 per camper. The cost is similar to the fees charged by other residential summer camp programs that do not include the healthy lifestyle lessons, counseling, and special diet. In fact, using the Thomson Medstat Research Brief (www.medstat.com/pdfs/childhood_obesity.pdf), the annual health care cost is estimated to be about $6700 for a child treated for obesity covered by Medicaid and about $3700 for an obese child with private insurance. Therefore, the cost to attend the Kamp K’aana program is reasonable. We are collecting follow-up data to document the potential long-term benefits of the Kamp K’aana program.
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