Obese children often struggle with poorer self-esteem than their normal-weight counterparts, with higher body mass index (BMI) z scores predicting poorer self-esteem (1). Weight-related teasing has been shown to contribute to lower self-esteem among obese children (2). In a residential weight-loss camp program carried out in the United Kingdom, greater weight loss was reported to be associated with greater psychological improvement (3). If obese children are given the opportunity to improve their self-esteem among peers in a safe environment with no teasing, then they may enhance their ability to achieve a healthy lifestyle and reduce body weight. A summer camp may offer such an opportunity for obese children to improve their self-esteem among their peers and to achieve a healthy lifestyle.
This article describes the preliminary results of Kamp K'aana, a 2-week summer camp program, on a group of obese, multiethnic children from a diverse socioeconomic background.
A total of 21 obese children (Table 1) between 10 and 14 years of age were enrolled in the pilot summer camp program. To participate in the program, the children had to be 10 to 14 years of age at the time the summer program started with a BMI equal to or greater than the 95th percentile for age and sex. Children with a variety of medical conditions, such as hypertension and diabetes, were included unless they had a condition that prevented participation in summer camp activities, as judged by their pediatricians. Scholarships were provided for 10 of the children and the others paid the camp tuition of $1400 for the 2-week session. Only children who received government health care assistance such as Medicaid were considered for scholarship.
The study 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.
K'aana is an Alabama Coushatta Indian word meaning health. The primary goals of Kamp K'aana were to provide activities to improve the self-esteem of the children, to instill the benefits of physical activity and good nutrition in its participants, and to give the children and their families the tools to support a long-term healthy lifestyle.
The children received 6 behavioral lessons and 4 physical activity/nutrition lessons that were each 1 hour in duration to provide them with the knowledge and skills to achieve a healthy lifestyle. The behavioral lessons included journaling, goal setting, understanding and changing eating patterns, listening to your body, body signals, joy of eating, problem solving and planning, helping others help you, food traps and food pushers, and positive thinking and preventing slip. The physical activity/nutrition lessons included aerobic exercise; rate of perceived exertion; water and hydration; dairy, calcium requirement, and sources; fruits and vegetables (vitamins, minerals, and fibers); grains (source of energy, satiety, fiber, and benefits); meat group; build-a-meal; dining out; get a grip on portion size; food labels; and sugar in drinks. These lessons were reinforced by serving a Traffic Light Diet menu during camp (4). The Traffic Light Diet menu provided the children with 1800 calories per day (450 kcal for breakfast, 600 kcal for lunch/dinner, and 150 kcal for afternoon snack). An example of a single-day menu is shown in Table 2. The menu met the US Dietary Guidelines and Recommended Dietary Allowances for Nutrients and was served in cafeteria style with only 1 pass with controlled serving size and unlimited salad bar. One premeasured container of salad dressing was provided. The foods were labeled red, yellow, and green according to the Traffic Light Diet menu, and the children were taught to recognize and to consume red zone foods judiciously, yellow zone foods moderately, and green zone foods regularly. On the last 2 days of camp, meals were served in multiple portions in large serving dishes for self-serve with several campers sitting at a table together to challenge the children on their new nutrition skills and knowledge.
We also enlisted the support of the parents to provide an environment at home to help their children to maintain a healthy lifestyle after the 2-week summer camp. At the orientation given when the campers arrived, parents completed a Home Barriers Healthy Eating Scale questionnaire (http://www.kidsnutrition.org/faculty/Survey_documents/GEMS(2001-2).htm). The parents also received handouts developed by our staff on nutrition and parenting or fact sheets developed by the American Heart Association, the American Dietetic Association, the American Cancer Society, the US Food and Drug Administration, and the US Centers for Disease Control and Prevention. The handouts and fact sheets included “Eating Better Together,” “Eating Out and About,” “Learning Label Language,” and “Some Quick Parenting Tips.” The staff explained the content of these handouts and fact sheets to the parents during orientation. Parents were also given a calendar with daily homework assignments including asking them to remove all high-calorie snacks in their kitchen cabinets, replacing them with healthy snacks, and limiting screen time to encourage their children to maintain their healthy habits after camp.
Body weights and heights of the children were measured in duplicate at the beginning and again at the end of the 2-week program. The average weight and height values at each time point were used to calculate BMI. Blood pressure (BP) and heart rate of the children also were measured at the beginning and at the end of the 2-week summer camp program.
Each child completed the Self-Perception Profile for Children (SPPC) (5) at the beginning and at the end of the 2-week program to document potential changes in self-esteem. The SPPC is a 36-item self-report scale designed to tap children's judgments of their competence, as well as a global perception of their worth or self-esteem. It consists of 5 specific domains: scholastic competence, social acceptance, athletic competence, physical appearance, and behavioral conduct, as well as a general domain of global self-worth. Each domain consists of 6 questions and the questions are not in sequential order in the SPPC questionnaire. Each question has 4 potential answers, and each answer is assigned a score between 1 and 4. The score for each domain is the average sum of the scores for each of the 6 questions. The internal consistency of the SPPC scales is satisfactory with Cronbach α between 0.73 and 0.81. The test–retest reliability of the SPPC over a 4-week interval is good, with all intraclass correlation coefficients at 0.84 or higher. More specifically, the scale correlates in a theoretically meaningful way with child, parent, and teacher reports of psychopathology and personality (6).
To document the effect of Kamp K'aana on cardiorespiratory fitness, each child participated in a FITNESSGRAM Progressive Aerobic Cardiovascular Endurance Run (PACER) test in which the child moved between 2 marker cones 20 m apart at the sound of a tone (7). The goal was to arrive at the other cone by the sound of the next tone. The pace increased every minute, requiring the child to move faster between the cones, eventually at a running pace. The test ended when the subject was unable to arrive at the opposite cone by the sound of the tone. The outcome was the number of successfully completed laps. The PACER test was administered at orientation and at the end of the 2-week summer camp program. The PACER test, a criterion-referenced method to evaluate cardiorespiratory fitness among school-age children, has been evaluated to be appropriate for children at the third grade level.
To document the effect of Kamp K'aana on physical activity performance, each child's muscular strength, muscular endurance, and flexibility were evaluated at the beginning and at the end of the 2-week summer camp program (8). Muscular strength and endurance were evaluated based on the number of curl ups and push-ups that a child could perform in a fixed amount of time according to the procedures described under the FITNESSGRAM reference guide for children (8). Flexibility was evaluated based on the backsaver sit-and-reach measurement. In this procedure, the child was seated on a mat on the floor, with 1 leg extended in front, with the foot flat against the measurement box. The other leg was positioned with the knee bent comfortably in front and the foot flat on the floor. The child was asked to reach forward with both hands along the scale and hold the position for 1 second. The outcome was the farthest reach of 3 trials measured in inches.
A paired-samples t test was used to evaluate the changes in body weight, BMI, BMI z score, self-esteem, BP, heart rate, and physical activity performance at the end of the 2-week program. An independent-sample t test was used to evaluate the potential effect of sex on these changes.
As shown in Table 1, the campers had an average age of 11.4 ± 1.4 years. All were obese based on BMI (32.4 ± 4.7 kg/m2), BMI percentile (98.5 ± 1.4), and BMI z score (2.30 ± 0.33). The campers consisted of 12 Hispanics, 8 whites, and 1 African American. There were 5 boys and 16 girls who came from a diverse socioeconomic background, with 10 children requiring scholarships to attend Kamp K'aana.
At the end of the 2-week camp, the overall SPPC score was significantly improved (P < 0.01), and the improvement was greater among the girls (+0.37 ± 0.28 unit) than the boys (−0.07 ± 0.24 unit, P < 0.01). The overall improvement in self-esteem was a result of positive changes in their self-perception of social acceptance (+0.26 ± 0.28 unit, P < 0.01), athletic competence (+0.30 ± 0.61 unit, P < 0.04), physical appearance (+0.50 ± 0.61 unit, P < 0.01), and global self-worth (+0.29 ± 0.55 unit, P < 0.03). Among the 4 specific domains, only athletic competence showed significant difference in scores among the girls (+0.45 ± 0.56 unit) when compared with the boys (−0.17 ± 0.57, P < 0.05). As shown in Table 3, the scores for athletic competence and physical appearance were significantly below (P < 0.04 by 2-sample t test) those reported among normal-weight girls (9). The score for global self-worth was marginally lower (P = 0.06) than that reported among normal-weight girls. However, after the 2-week Kamp K'aana program, these scores improved significantly and reached normalcy.
Figure 1 shows that the 2-week Kamp K'aana program led to a reduction in body weight of 3.7 ± 1.2 kg (P < 0.01) and BMI of 1.6 ± 0.5 kg/m2 (P < 0.01). The reductions in weight and BMI were significantly higher among the boys (5.2 ± 0.4 kg; 2.2 ± 0.3 kg/m2) than among the girls (3.3 ± 1.0 kg; 1.4 ± 0.4 kg/m2, P < 0.01). Not shown in the figure, the BMI z score with adjustment for age also was reduced by 0.12 ± 0.06 units (P < 0.01) with no significant sex difference (P > 0.38).
Although none of the children were diagnosed with hypertension at the beginning of the program, the systolic BP, diastolic BP, and heart rate were reduced by 10.8 ± 13.4 mmHg (P < 0.01), 9.8 ± 5.5 mmHg (P < 0.01), and 8.2 ± 12.7 bpm (P < 0.01), respectively, at the end of the program with no sex differences.
The fitness tests revealed no significant changes after 2 weeks in cardiorespiratory fitness (PACER test), in muscular strength (push-ups) and in flexibility (sit and reach). Significant improvement was reported only in muscular endurance (number of curl ups = 11 ± 22 counts, P < 0.03). The improvement was significantly higher among the boys (29 ± 37 counts) than among the girls (5 ± 10 counts, P < 0.03).
The weight change observed in our pilot summer camp program for obese children compares favorably with high-quality, traditional weight control programs that take place weekly or twice weekly (10,11). We were surprised by not only how much weight the children lost during this 2-week experience but also by how profoundly the program affected their self-esteem. At the beginning of the program, the children's self-perception scores for athletic competence, physical appearance, and global self-worth were below the scores of normal-weight children (9). However, at the end of this 2-week program (Table 3), not only was there significant improvement in these scores but they were also found to be similar to those reported for normal-weight children. The small number of boys in the pilot program probably biased the interpretation of the sex differences, and a larger sample size with more boys is needed to clarify this observation.
The residential structure of this program is an important part of its success. The caloric restriction is moderate and physical activities are varied, typical camp activities, making the experience enjoyable rather than stressful. The campers are in a group, with supportive, encouraging counselors and separate from campers who are not addressing weight. This setting seemed to reduce self-consciousness, improve willingness to participate in activities, and lead to the development of close friendships common at other residential camps.
The lack of significant improvement in cardiorespiratory fitness, muscular strength, and flexibility may be related to the short duration of the program. The children that attended this camp, and probably most obese children are not used to the kind of activities that were provided by the program. As a result, some of the participants complained of feeling tired and sore at the end of the 2-week program. This may have interfered with their performance in the fitness tests. Alternatively, the lack of improvement may reflect a limitation of the assessment. Although the PACER test is a criterion-referenced method to evaluate cardiorespiratory fitness among school-age children, this test may not be appropriate for obese children because many of the campers were not able to complete even the warm-up level of the test.
Several reports have shown the benefits of a residential summer camp program toward self-esteem and body weight (12). For example, a residential camp program in the United Kingdom has demonstrated good effects on weight and self-esteem (3,13,14). This residential camp program, however, has a rather homogenous population and varied treatment duration. Another 8-week residential camp program on boys between 8 and 18 years of age also showed benefit on body weight but improvement in self-esteem was reported only among the younger children (15). In contrast, Kamp K'aana demonstrated a powerful effect in a group of campers from a diverse socioeconomic background with a large number of Hispanic children. The intervention was relatively short, and the cost ($1400) was on the lower end of typical residential summer camp programs with typical (nonweight oriented) summer camp curricula. The longer residential camp programs reported earlier would have been too costly for most families, particularly among the low-income families who are most affected by the epidemic of childhood obesity. All of these facets suggest that the 2-week Kamp K'aana program can serve as a model for other communities.
The lack of a control group is a drawback of the pilot Kamp K'aana program but is typical of any pilot programs that are staffed by volunteers with no external support. However, proposals have been submitted to funding agencies to confirm the long-term efficacy of the Kamp K'aana program with larger sample size and a control group.
The Kamp K'aana program fulfilled the recommendation of the Institute of Medicine and the National Academies of Science that encouraged community organizations to collaboratively develop and promote programs that encourage healthful eating behaviors and regular physical activity among high-risk populations such as obese children. The cost of $1400 still is difficult for the underserved population. However, successful outcomes of the program may provide incentives for health insurance to consider Kamp K'aana a reimbursable treatment program and, thus, allow the program to be available to high-risk populations.
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