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Diet and lifestyle

Danish treatment model works: 3 of 4 children lose weight and keep it off

Dieting has a reputation for only working briefly; many people regain all the weight they have lost once the focus declines. Now researchers have monitored 1001 overweight children for 18 months who followed what has been dubbed the The Childrens Obesity Clinics Treatment model (TCOCT). The results are revolutionary: 3 of 4 children maintained their weight loss based on one annual discussion with a mentor lasting just 5 hours. Even the children’s parents lost weight.

According to the Danish Health Authority, 1 of 25 children in Denmark are obese. Most have to struggle with the social, mental and especially physical effects of obesity. In addition to greatly impaired quality of life, they often face a lifelong battle against obesity, with much greater risks of cardiovascular disease, diabetes, cancers and premature death. For years, researchers worldwide have unsuccessfully attempted to alter the daily lives of obese children to change their habits and enable them to lose weight, and keep it off. Now a Danish method has proved to be successful.

“This is a paradigm shift in treating obese people – a completely new method of health education that we have now shown has not only temporary effects but also lasting impact. Three of 4 children still had a substantially reduced body mass index after 18 months,” explains Jens-Christian Holm, consultant, Department of Paediatrics, Copenhagen University Hospital Holbæk.

Five hours is enough

The researchers monitored 1001 children and adolescents 3–18 years old from June 2013 until December 2015. They recorded the changes in the children’s hip and waist sizes and their body mass index (BMI): weight (in kg) divided by height (in metres) squared (kg/m2). Although children’s BMI increases naturally as they get older, the researchers measured how much a child’s BMI deviates from the average of children of the same age: the standard deviation score.

“A BMI standard deviation score of less than 1 indicates normal weight. A score between 1 and 2 indicates a risk of being overweight. The boys in our study had an average score of 2.85 and the girls 2.48. Both scores suggest that the children were obese. After 18 months, the boys’ average scores fell to 2.47 and the girls’ fell to 2.30. Although they were still overweight, they had made significant progress towards achieving more normal weight.”

Dubbed the TCOCT model, Jens-Christian Holm and colleagues developed it as a treatment method that involves health professionals spending only 5 hours per child per year to draw up a specific plan with the parents and the child – and follow up and adjust the treatment plan.

“In principle, the children and their families must actually implement the plan. While the TCOCT model provides knowledge and understanding, dignity, empathy and great service are decisive. The guiding rules on lifestyle they take home are easy to understand and implement and provide clear results.”

24/7 for life

Jens-Christian Holm has created approximately 100 rules, but each family only takes home 14–22 tailor-made ones. Examples of rules include serving dinner on a plate rather than in a pot, pan or dish and giving any second helpings 20 minutes afterwards. Children may only spend 2 screen hours per day and not before 17:00. They must also play a sport twice a week and may only have sweets and sugary drinks once a week in agreed quantities.

“Although the rules may appear restrictive, they basically express caring. We all know that you should not feel sorry for children who are prohibited from eating sweets. However, you should feel sorry for them if they are allowed to eat too many sweets.”

According to Jens-Christian Holms, the decisive revelation for the TCOCT model is that obesity is a chronic condition. This revelation is especially important to implement in the educational aspects of treating obese children.

“These children and their parents need to understand that the treatment applies 24/7 for the rest of their life. Just like all other illnesses, problems occur when someone forgets their medicine. This also applies to people who are obese if they ignore the rules for 6 or 12 months. In contrast, sticking to the rules for life not only improves the quality of life but also makes it longer and happier.”

Hormones at work

The key to the success of the TCOCT model is that parents and children not only adopt all the diet and life rules and transform them into their own life choices but also learn to manage their lives based on the new rules. By succeeding they benefit in two ways.

The TCOCT model: six of the rules
• Do not skip meals.
• Fast food is permitted no more than once per month.
• Sweets and sugary drinks are allowed once per week.
• Be physically active and exercise twice per week.
• TV and computer for no more than 2 hours daily and not before 17:00.
• Deposit the children’s allowance into a bank account – not giving it to them in cash – to avoid spontaneous purchases.

“The care we provide becomes self-care that they implement in their own lives, and this applies not only to the children. Parents play such an important role in the process that they often transform their own lifestyles. Our research therefore also shows that parents lose considerable weight, and the children also reduce their elevated blood pressure and serum cholesterol and improve their quality of life, appetite and body image.”

The children’s weight loss was both substantial and apparently long-lasting. The boys had the greatest reduction in BMI standard deviation scores. However, the girls’ average waist size declined by 5.1 cm, more than the boys’ 3.8-cm reduction.

“The boys especially lost weight continually during the 18 months we monitored them. However, the girls’ weight loss varied more. We do not yet know why, but we think that it is caused by the differences in sex hormones and body composition.”

Global dissemination

Obese children and their parents face powerful physical and societal forces. People’s fat tissue is regulated by a complex hormone system that has constantly strived to preserve and protect fat accumulation for hundreds of millions of years. However, in a modern society in which people live sedentary lives without any great need to protect themselves against the weather and wind, this type of protection is superfluous and often harmful.

“Obese people experience severe physical and mental complications that increase ill health, reduce life expectancy and disable them in numerous ways. In many senses, our treatment completely contradicts most modern health education methods because we do not delegate the responsibility to individuals but instead intervene and set the framework that is required to change their lifestyles.”

Jens-Christian Holm has trained more than 600 treatment specialists throughout Denmark, and the methods produce the same results regardless of geography, degree of obesity or social status. Since the healthcare system only needs to spend 5 hours per year on each obese child, Jens-Christian Holm believes that dissemination needs to be accelerated rapidly.

“Our new research shows that the TCOCT method achieves the most reliable long-lasting weight loss so far for children anywhere in the world. Our initial goal is therefore to disseminate the method to the rest of Denmark. However, in the long term, we believe that this method may contribute to saving children and their parents globally from the serious effects of the obesity epidemic,” concludes Jens-Christian Holm.

A hospital-based child and adolescent overweight and obesity treatment protocol transferred into a community healthcare setting” has been published in PLoS One. In 2012, the Novo Nordisk Foundation awarded a grant to Jens-Christian Holm, a main author, for the project Prediction of Childhood Obesity Treatment Outcomes by Markers of Leptin and Insulin Functionality: Interaction with Inflammation and the Gut Microbiome. Several co-authors are affiliated with the Novo Nordisk Foundation Center for Basic Metabolic Research.

Jens-Christian Holm
Clinical and Research Associate Professor
MD Jens-Christian Holm, PhD is a Consultant in Paediatrics, Clinical and Research Associate Professor, and Head of The Childrens’ Obesity Clinic, Department of Paediatrics, University Hospital Holbæk, Denmark. In 2007, Jens-Christian Holm established The Childrens’ Obesity Clinic (TCOCT) – a multidisciplinary childhood obesity chronic-care treatment facility. TCOCT is unique, and offers families a paradigmatic shift in approach by understanding child obesity as a chronic disease. We understand that the fat mass is endocrinologically regulated and offer a unique and successful treatment protocol. TCOCT offers an innovative pedagogy providing empathy, self-identification and authenticity. This treatment approach has reduced obesity among 70-75% of participating children and adolescents enrolled in both hospital and primary municipality clinics. It also improves family health.