„PoZdro!” jako przykład skutecznego wieloośrodkowego programu zwalczania otyłości i promowania zdrowego stylu życia u dzieci i młodzieży w Polsce – protokół badania oraz doniesienia wstępne z pierwszego ośrodka

Introduction

Overweight and obesity prevalence in children and adolescents increase in developed and developing countries worldwide for more than 30 years [1].
There are no consistent data about obesity problem among children in Poland. Available national data from 2007–2009 show that the prevalence of overweight and obesity among adolescents aged 13−18 years was in the range of 14.6−19.4% and 10.3−13.0%, boys and girls, respectively, using international definitions of childhood overweight [2]. Although obesity rates among children and adults are becoming one of the main public health issues, no effective national policy to tackle this problem has been formulated yet.
This paper describes the concept, protocol and preliminary results of the largest obesity management programme for adoles-cents in Poland – “PoZdro!” (National Programme for the Prevention of Diabetes and Lifestyle Diseases) – initiated by Medicover Foundation and funded by a grant from the Jochnick Family Foundation.

Material and methods

The Programme is a multicenter before and after intervention non-controlled study measuring the effectiveness of the integrated be-havioral intervention in adolescents on their body mass index and body composition.
“PoZdro!” is based on three main steps: screening, interdisciplinary intervention and education activities in secondary schools. Study structure and patients flow is presented in Figure 1.

Screening – comprehensive health assessment

The screening is carried out by the specially trained nurses in secondary schools from four cities in Poland – Gdynia, Lublin, Wroc-law and Warsaw.
The main screening procedure and reference points are outlined in Table I. All children taking part in the screening must have provided written parental consent. An additional questionnaire, focused on nutrition-related behaviors and physical activity, was given to all parents participating in the programme.
Educational materials, summary of screening results and clinical recommendations were provided to parents of all children who took part in the screening. If a life-threatening condition or a major health problem was discovered, the child was referred to a pediatric department or a GP.

Intervention – Individual Integrated Care

All children with BMI above the 90th percentile for age and sex according to actual polish centile charts [3] were invited to take part in a two-year-long intervention programme.
The Individual Integrated Care (IIC) programme consists of eight consultations delivered in outpatient Medicover Centers scheduled in the following intervals: at 0–6 weeks, 3 months, 6 months, 9 months, 12 months, 18 months, and 24 months. During each visit the patient (and their parent/s) undergoes a series of tests and consultations with a physician, dietician, psychologist, and a physical activity specialist.
Additionally, after the first and before the last visit, laboratory tests for biochemical markers of diabetes and cardiovascular risk are carried out as presented below.
Anthropometry: Body weight and height are measured with a digital scale (Mensor WE150, Poland), with the child in the standing position, in underwear and barefoot. Polish centile charts are used to assess BMI [3].
Waist and hip circumference are measured on a horizontal plane using the Ergonomic Circumference Measuring Tape (model 201; Seca GmbH & Co, KG, Hamburg, Germany). Polish reference values are used to assess abdominal obesity [4].
Blood pressure measurements: Arterial blood pressure is measured on the left arm at the heart level, using an oscillometric technique (Omron) with adequate cuff size, with the child sitting down, legs uncrossed, and with at least 5 minutes’ rest in sitting posi-tion before the measurement. Three separate measurements of blood pressure are taken and their average value is recorded [5].
Diet assessment: Dietary journals covering three consecutive days (2 weekdays + 1 day of the weekend) prior to joining the programme and at the end of the programme are analysed – caloric intake and dietary intake of nutrients are calculated with validated Dieta 5.0 software (Institute of Food and Nutrition, Warsaw).
Psychological assessment of readiness to change is based on Prochaska model (validated structured interview) [6]. The aim of psychological consultations is mostly strengthening the motivation of the child and their parents to introduce healthy lifestyle changes.
Consultations with a physical activity specialist aim at assessment of body posture defects, muscular strength development, as-sessment of cardiorespiratory fitness [7] based on the results defining optimal levels of physical activity, adjusted to child’s body mass, abilities and preferences, developing a training programme with gradually increasing intensity.
Biochemical measurements include complete blood count, lipid profile (enzymatic method); oral glucose tolerance test (OGTT) with concentration of glucose (hexokinase method) and insulin (immunochemiluminescence assay); alanine transaminase (ALT), thyroid stimulating hormone (TSH), free thyroxine (fT4).

Educational workshops

Parents and children are invited to take part in educational workshops run by a dietician, psychologist and workshop on food mar-keting, labelling and sugar dependence. These 6-hour-long workshops delivered in cities conference centers are developed to enhance motivation, provide knowledge and create a positive attitude towards lifestyle changes.

Results

Preliminary results from Gdynia

In this paper we present preliminary data from the first city involved in the programme – Gdynia. Full data from all cities and years of programme will be presented after fulfillment of the programme, in 2020. 3998 children (63% of Gdynia 13-years-old population) were screened during 2013–2017 screening phase. Out of that number 643 children (16.0%) were overweight and 190 (4.7%) were obese. Overweight and obesity rates were higher in boys (17.7%; 6.2%) than in girls (14.4%; 3.3%).
Out of the children with overweight and obesity 603 (15,1%) with BMI above 90th centile were qualified to the interventional part of the programme. Out of 603 qualified children (QUA), 470 (77.94%) were engaged in IIC. From the 470 engaged in the IIC 253 (41.96% of QUA; 53.83% of IIC) finished all 8 visits. The highest dropout rate was observed after the 1st visit (15.74%).
The analyses showed that children who completed the whole intervention programme had significantly higher decrease in BMI centile, SBP and DBP as well as in total body fat. Details are presented in Table II.
When assessing changes in BMI centile on a literature established success ratio [8] – measured as decrease in BMI centile ≥ 5 there is a significant difference between those two groups: 66 vs. 41 participants (26.19% vs. 18.98%, Fisher’s exact test p val-ue = 0.0404) fulfilling that criteria. The mean decrease in BMI centile in the group that completed the whole intervention programme was 3.04, whereas in the lost-to-follow-up or discontinuation group the BMI centile decreased only insignificantly.

Discussion

“PoZdro!” is the only obesity prevention and management programme in Poland operating simultaneously in four big cities. The programme was designed according to the best available (in 2013) evidence [9] and it includes significant parental engagement and long-term behavioral intervention. The authors of the programme aimed to create an effective intervention in the field of childhood obesity, adapted to the local Polish environment as there are no national programmes of children obesity management including individual health assistance.
Presented results show that the participants who finished the whole two year programme had a significantly higher decreasing rate in BMI. 25% of participants from Gdynia achieved 5.0 centiles BMI reduction, which is much above the average comparing to previously published data [10]. Moreover, presented data show to-date biggest documented reduction in the percentage of the body fat among the patients who finished the programme.
As previously mentioned, these results only represent data of 603 children (from the first introduced city) out of over 2000 in-cluded in the intervention until the end of the year 2019. Further analyses from all four cities are necessary to discuss the effect of the programme on metabolic risk of the studied group.

Conclusions

“PoZdro!” programme is the first in Poland multicenter before and after intervention programme build as a response to increasing obesity problem in adolescents. Based on available recommendations and standards, the programme was created as an interdisciplinary, longitudinal activity focused not only on body mass index decrease but change of lifestyle behaviors in adolescents and their families. The preliminary results show that those participants who decided to participate had a visible change in body mass index and body fat percentage through the two year intervention process.

Ethics approval and consent to participate

All parents of students participating in the screening and in the intervention stage have provided written consent for the screening of their children.
The screening protocol and the intervention protocol have been approved by the Independent Bioethics Commission for Re-search at the Medical University of Gdańsk (NKBBN/301/2014).

Funding

Total budget of the programme: 15.481.000 PLN (3.680.956 EUR).The “PoZdro!” programme is financed by Medicover Founda-tion by a grant from the Jochnick Family Foundation.
The Jochnick Family Foundation had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Acknowledgements

The authors express their gratitude to all participants, their parents and members of the “PoZdro!” team for their input into the study. The authors would also like to thank the Medicover Foundation administrative staff for their help in conducting the study.

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