International Journal of Obesity (2000) 24, 1445±1453
ß 2000 Macmillan Publishers Ltd All rights reserved 0307±0565/00 $15.00
www.nature.com/ijo
The effects of a children's summer camp
programme on weight loss, with a 10 month
follow-up
PJ Gately1*, CB Cooke1, RJ Butterly1, P Mackreth1 and S Carroll1
1
School of Leisure and Sports Studies, Leeds Metropolitan University, Fairfax Hall, Beckett Park, Leeds LS6 3QS, UK
OBJECTIVE: To assess the long-term effects of a multidisciplinary approach involving structured fun-type skill learning
physical activities in the treatment of obese and overweight children.
DESIGN: A longitudinal investigation incorporating repeated measurements before and after the 8 week intervention
and after the 44 week follow-up period.
METHODS: The camp programme (Massachusetts, USA) utilised structured fun-based skill learning physical activities,
moderate dietary restriction and behaviour modi®cation. The primary aims of the intervention were to reduce body
mass and promote the maintenance of the reduction in body mass using an alternative to standard exercise
prescription.
SUBJECTS: One-hundred and ninety-four children (64 boys and 130 girls, aged 12.6 2.5 y) enrolled at a summer
weight loss camp, of which 102 children (38 boys and 64 girls aged 13.6 2.4 y) returned 1 y later.
MEASUREMENTS: On commencement of the programme all children were assessed for body mass and stature. At
follow-up, data was available on 102 subjects for body mass and stature.
RESULTS: Over the 8 week intervention signi®cant reductions (P ˆ 0.00) in body mass were obtained. During the 44
week follow-up signi®cant increases (P ˆ 0.00) were noted in body mass, body mass index (BMI) and stature, but as
expected there were large variations in the responses. One year after the initial measures had been taken mean body
mass and BMI were lower than at the start of the intervention, BMI signi®cantly so (week 0, 32.9 7.4 kg=m2; week 8
29.1 6.5 kg=m2; week 52, 30.05 7.04 kg=m2); (P ˆ 0.00). Stature increased signi®cantly (week 0, 1.58 0.12 m; week
52, 1.64 0.11 m) (P ˆ 0.00) during this period, demonstrating a reduction in mean body mass over a 1 y period whilst
subjects continued to increase in stature. When changes in BMI are analysed with the use of standard scores, there is
a non-signi®cant increase (P ˆ 0.07) in BMI during the follow-up phase and 89% of children had a lower BMI than at
week 0.
CONCLUSIONS: These ®ndings suggest that the use of a structured fun-based skill learning programme may provide
an alternative method of exercise prescription to help children prolong the effects of the 8 week intervention. Further
investigations will help identify the key factors that are necessary for long-term lifestyle modi®cation.
International Journal of Obesity (2000) 24, 1445±1452
Keywords: childhood obesity; physical activity; multidisciplinary approach; weight loss
Introduction
Obesity is recognized as a major cause of morbidity
and mortality and has been identi®ed as a major factor
in a range of hypokinetic diseases.1,2 Trends described
from the National Health and Nutrition Examination
Surveys (NHANES) indicate a dramatic increase in
overweight prevalence in the US adult and paediatric
populations.3,4
Numerous studies have reported short-term success
in the treatment of obesity.5 ± 7 However, these studies
contain methodological problems (small sample, lack
of control over energy intake, problems in assessment
*Correspondence: PJ Gately, School of Leisure and Sports
Studies, Leeds Metropolitan University, Fairfax Hall, Beckett
Park, Leeds LS6 3QS, UK.
Received 31 March 1999; revised 21 January 2000; accepted
3 April 2000
of physical activity) and follow-up measurements are
rarely carried out. Most studies have been conducted
on adult subjects and have shown that intervention
strategies are dif®cult to maintain.8,9 This lack of
success is attributed to adjustments in dietary intake
when subjects return to their normal environment,10 or
poor adherence to exercise.11
Many treatments of obesity have used dietary
interventions to effect a negative energy balance.12
However, researchers have identi®ed that some subjects undertaking dietary interventions may become
susceptible to over-eating and success in dietary
programmes is limited.7,8
It has been suggested that obesity may be due to a
lack of physical activity.13,14 Researchers have suggested that physical activity is necessary to increase
energy expenditure, decrease appetite, positively
affect eating behaviour, improve cardiovascular functioning and psychological well being.14,15 Despite
Children's weight loss programme
PJ Gately et al
1446
these ®ndings, little is known about what factors affect
adherence. Parker16 has suggested that structured funtype exercise is a form of intervention which can be
used to promote adherence and motivation to develop
habitual physical activity which will lead to an
increase in energy expenditure and positive changes
in body mass. An alternative approach to structured
physical activity prescription has been proposed by
Epstein,17 which involves the reduction of sedentary
behaviour which has a positive effect on physical
activity levels. This research illustrates that alternatives to structured physical activity prescription
should be developed to investigate their potential
for improving adherence to physical activity
interventions.
Approaches which have used diet and exercise to
effect reductions in body mass are more successful than
diet or exercise alone.5,18 ± 21 Many programmes, however, are short-term in nature and do not educate the
participants or provide them with the necessary skills to
maintain their reduced body mass. In general, results
have been disappointing, with typical treatments resulting in a 5 ± 20% reduction in body mass, only to return
to original levels of body mass within 5 y.8
Some studies have produced some success during
follow-up programmes. Pavlou's15 study on Boston
policemen in a work-centred programme demonstrated a signi®cant reduction in body mass using a
combination of dietary restriction and exercise and
illustrated a non-signi®cant change in body mass in
the subjects who continued to exercise during the 18
month follow-up phase.
There have been numerous studies undertaken on
the treatment of obesity in the adult population. In
contrast, there has been little work carried out on the
paediatric population.10,11 This would seem to be
problematic, given that levels of inactivity and obesity
persist into adulthood.22 ± 26 Indeed evidence continues
to mount with regard to the risks associated with
obesity during childhood, signi®cant morbidity being
the immediate consequence and increases in adult
mortality also being highlighted by a number of
studies.27,28 Many practitioners see obesity as a dif®cult problem to treat, as there is limited success from
interventions.7 Without research evidence on appropriate interventions for children the likelihood of
developing appropriate treatments for this population
is low.
Despite this, Epstein17 has proposed the use of
behavioural interventions to increase participation in
physical activity, rather than using regimented exercise to affect reductions in body mass. In addition,
these interventions offer the opportunity of establishing longitudinal effects, as they have been followed
up over 5 and 10 y, with data provided by Epstein29
illustrating that 34% of the sample decreased percentage overweight by 20% or more and 30% were no
longer obese. These longitudinal studies demonstrate
the importance of multifactorial methodologies using
diet, physical activity and behaviour modi®cation.
International Journal of Obesity
The aim of this study was to evaluate the overall
effects of a multifactorial intervention for reducing
body mass in children using moderate calori®c restriction, educational and behavioural modi®cation and a
structured fun-based skill learning physical activity
programme. The acute effects of the 8 week programme were assessed pre- and post-treatment with a
follow-up after a further 44 weeks.
Methods
Eight-week programme
One-hundred and ninety-four children (64 boys and
130 girls aged 12.6 2.5 y) enrolled on the camp
programme. The programme is a traditional residential summer camp in a rural setting (Massachusetts,
USA) with a speci®c aim of weight loss. The very
nature of the programme prohibits the opportunity of
identifying an appropriate control group. In addition,
this type of programme is restricted to children of
higher socio-economic status, although a number of
children were supported by assisted places or social
services funding.
Follow up
One-hundred and two children (38 boys and 64 girls
aged 13.6 2.4) re-enrolled on the camp programme
1 y later. All subjects were assessed for body mass and
stature. All measures were taken by the same
researcher during the initial programme and the
follow-up. No signi®cant differences were found in
any of the variables between the returners and nonreturners. As part of the camp programme a selection
of non-returners were contacted to investigate reasons
for non-return. A variety of reasons were identi®ed by
the parents or children for not returning to the camp.
These included families who reported that their child
had continued to lose weight and did not need to
return to the camp and families who reported that their
child did not enjoy their experience at camp the
previous year. There seemed to be no common
responses or reasons for children not returning. It
must be noted that this information was purely observational data recorded by the camp programme rather
than the current investigators, so caution must be
taken when interpreting this information.
One confounding factor in the analysis of longitudinal data for children is growth, which will signi®cantly affect body mass during the intervention
and follow-up. The contribution of growth to the
change in body mass over the follow-up therefore
has to be accounted for within the present study. The
use of population data for comparison is problematic,
due to the sample of obese children not being comparable to the normal population data provided by the
National Center for Health Statistics (NCHS). Data on
differences in the patterns of growth for obese and
non-obese children have been reported by Epstein.30
Children's weight loss programme
PJ Gately et al
In addition, Van Lenthe31 has identi®ed that rapidly
maturing children have a signi®cantly higher body
mass index (BMI) during adulthood. This research
illustrates the problems associated with assessing
obese and overweight children over a prolonged
period of time. Thus, the analysis of the data has
taken a number of forms to clearly present the data
and to attempt to account for the confounding effect of
growth on body mass. Each form has its limitations
but the general pattern of the analysis may help
illustrate the pattern of change during the follow-up
period. The forms of analysis include change in body
mass, change in BMI, comparison of change in body
mass and stature with NCHS data and change in
standardised BMI scores.
The physical activity programme
The physical activity programme was based on activities designed to provide children with a wide range
of fun-type skill learning experiences, and to improve
physical ®tness and con®dence within a sporting and
exercise environment. Each session was conducted
by a specialist instructor. The ®rst 2 weeks of the
programme were speci®cally aimed at developing
children's sports skills, cardiorespiratory ®tness,
exercise tolerance and the prevention of injuries
through appropriate awareness and body preparation.
The following 6 weeks involved further development
of children's sports skills and exercise tolerance.
During this part of the programme, the newly
acquired sporting skills were developed further offering an opportunity for children to be involved in
competitive activities, thus, providing children with a
number of positive experiences to help them maintain
their levels of activity on return to their normal
environment. The programme consisted of ®ve oneand-a-half hour sessions per day. These activities
included: one aerobic (eg orienteering), one waterbased (eg water polo), one circuit based (eg resistance training), and two games based sessions (eg
football, basketball). A wide range of activities were
provided so that children could experience a variety
of new activities.
Dietary restriction
All children underwent calori®c restriction throughout
the 8 week residential period. The calori®c restriction
was 5860 kJ=day (1400 kcal) provided as three meals
(breakfast, lunch and dinner) and two snacks in the
afternoon and early evening. In addition, the children
were observed during meals to ensure they did not
abstain from eating and also that they did not consume
more calories than permitted. The aim of the dietary
intervention was to cause suf®cient caloric restriction
to effect a reduction in body mass without causing
malnourishment or interruption in growth and maturation, but with suf®cient energy content so that
children could sustain the physical activities.
Behavioural and educational intervention
1447
Children took part in an educational programme
incorporating aspects of health, nutrition and physical
®tness. All sessions were conducted by quali®ed
professionals on a twice weekly basis. The purpose
of the sessions was to educate the children so that they
could develop the necessary knowledge to help minimize recidivism upon completion of the programme.
The sessions were informal, and included question
and answer elements as well as fun-type activities
such as quizzes and competitions.
A social cognitive model of behavioural modi®cation was incorporated within the camp programme.
Fox32 identi®ed that children's motives for participation in physical activity should be considered during
the development of appropriate interventions. Therefore, the programme included the following key elements; fun-type activity, skill-based sessions to
develop competence in a range of activities, choice
and a strong social component. These factors have
been identi®ed by researchers as key motives for
participation in physical activity.33 ± 35 This behavioural approach to physical activity was used to
improve self-ef®cacy and therefore increase participation in physical activity. In addition, during the 8
week programme parents attended a weekend of
classes involving training in nutrition, physical activity and long-term weight management. Parents were
instructed to act as role models to help reinforce the
behaviours that had been developed during the camp
programme.
Measures
Upon arrival all children were assessed for body mass
and stature. All measures were taken according to the
guidelines suggested by Lohman.36
The primary tools used for analysis during the
intervention and follow-up were body mass, BMI
and standardised BMI. BMI is a simple measure of
overweight and has been identi®ed by a number of
researchers as an appropriate tool for identifying
overweight in children and offering the opportunity
to predict overweight and health risks in adulthood.28,37 Hammer38 has suggested `for any index of
overweight to be meaningful in the paediatric age
group, there must be standards de®ned by age and
sex'. Therefore, NCHS39 standards were used to
develop age and sex-related standardized BMI
scores so that the children enrolled on the camp
programme could be compared to national reference
data. These data were also used to identify if there
were any differences between the expected increase in
stature and body mass of the normal population and
the actual increase in stature and body mass of the
sample during the 44 week follow-up period.
Body mass was recorded on a weekly basis during
the 8 week programme. All measures were taken by
the same researchers throughout the study. Children
were required to have a medical examination prior to
International Journal of Obesity
International Journal of Obesity
8
6
‡ 1.8**
( 7 11.1 ± 19.6)
30.1 7.0
(20.2 ± 62.3)
74.4 22.5
(33.1 ± 188.7)
72.3 23.6
(39.5 ± 186.69)
29.1 6.5
(18.2 ± 59.6)
28.3 6.4
(18.2 ± 58.9)
BMI, kg=m2(n ˆ 102)
BMI, kg=m2(n ˆ 194)
Body mass, kg (n ˆ 102)
Body mass, kg (n ˆ 194)
Data presented as mean, standard deviation and the range.
*P < 0.05; **P < 0.01.
13
12
82.2 25.9
(48.1 ± 201.9)
‡ 10.0**
( 7 20.4 ± 52.2)
13
7 10.8**
( 7 25.4 to 7 3.2)
7 11.2**
( 7 27.4 to 7 2.0)
7 3.8**
( 7 10.7 to 7 0.6)
7 4.4**
( 7 10.7 to 7 0.9)
13
1.64 0.11
(1.36 ± 1.93)
7 2.6**
( 7 15.2 ± 13.5)
2
7 1.3 ns
( 7 35.8 ± 37.19)
14
Percentage change,
weeks 8 ± 52
Change,
weeks 8 ± 52
1.58 0.12
(1.30 ± 1.88)
85.2 25.8
(36.3 ± 214.1)
83.5 26.6
(46.7 ± 214.1)
32.9 7.4
(20.2 ± 67.6)
32.7 7.2
(20.2 ± 67.6)
Results from the 8 week intervention and the followup phase for the 102 children are shown in Table 1. As
might be expected, the 8 week intervention produced
desirable changes of a large magnitude which were
followed by a reversal during the follow-up period.
However, the reversal that occurred during the followup period did not produce a return to the initial mean
values recorded at week 0.
Figure 1 illustrates the variation of responses to the
44 week follow-up period. It shows that 10% of
subjects continued to reduce body mass during the
follow-up period and 53% of subjects had a lower
body mass than when they had enrolled on the camp
programme 1 y previously. With regard to BMI,
Figure 1 shows that 26% of subjects continued to
reduce BMI during the 44 week follow-up period and
83% of subjects had a lower BMI than when they
were enrolled onto the programme.
One attempt to account for the confounding
effects of growth was to compare the present sample
with the 95th percentile for 13 ± 14 y-old children
Stature, m (n ˆ 102)
Overall changes
Week 52
During the follow-up phase for the sample of 102
children (38 boys and 64 girls aged 13.6 2.4 y)
signi®cant increases (P ˆ 0.000) were noted. Stature
increased by 4%, body mass by 14% and BMI by 6%
(Table 1). Independent t-tests were carried out on the
returners and non-returners. This analysis showed that
there were no signi®cant differences between groups
in terms of body mass (P ˆ 0.061), and the change in
body mass (P ˆ 0.809).
Percentage change,
weeks 0 ± 8
Follow up period
Change,
weeks 0 ± 8
In the sample of 194 children (64 boys 130 girls, aged
12.6 2.5 y) highly signi®cant reductions (P ˆ 0.000)
were achieved in body mass (Table 1).
Week 8
Eight-week intervention
Baseline
Results
Table 1 Effects of the 8 week programme (n ˆ 194) and the 44 week follow-up (n ˆ 102) on body mass, BMI, WHR and the sum of nine circumferences
Both a paired t-test and a one-way analysis of variance
with repeated measures were performed on the data for
the 8 week camp period and 44 week follow-up,
respectively. Statistical procedures were carried out
using SPSS. All results were considered signi®cant at
(P < 0.05), but actual computer-printed P values are
quoted in the results. A Scheffe post hoc test was used
for the one-way anova where appropriate. Finally, a
independent t-test was carried out to assess if there were
any differences between the returners and non-returners.
Change,
weeks 0 ± 52
Statistical analysis
‡ 0.06**
(0.01 ± 0.10)
Percentage change,
weeks 0 ± 52
acceptance at the camp and written informed consent
was also obtained from the parents.
Variables
1448
4
Children's weight loss programme
PJ Gately et al
Children's weight loss programme
PJ Gately et al
1449
Figure 1 Percentage of sample categorised according to changes in each variable during the 44 week follow-up period with respect to
baseline values.
using data from the NCHS percentiles.27 The 95th
percentile for stature and body mass has been chosen
as this is a more representative standard for this
sample. The change in boys mean stature over a 1 y
period for this sample was 7.00 cm, which is similar to
the NCHS data where the mean increase in stature was
6.9 cm. Within the girls sample, the change in mean
stature was 5 cm, which is higher than the NCHS
mean change of 3.2 cm. The change in boys' mean
body mass over the 1 y period for this sample was
11.78 kg compared to the expected change of 7.11 kg
from the NCHS data. The girls' change in mean body
mass over the 1 y period was 8.9 kg compared with an
expected gain of 5.78 kg from the NCHS data. These
data illustrate that a large amount of the increase in
weight can be accounted for by growth. A further
problem with the use of NCHS is that the majority of
the children in the present sample are signi®cantly
above the 95th percentile.
The 85th percentile has been identi®ed as an
appropriate tool for the de®nition of obesity.40 ± 42
Therefore, BMI scores were standardised in an
attempt to account for the confounding effects of
growth. This form of analysis is carried out using
the 50th percentile and the 85th percentile, as an
approximation of the population mean and standard
deviation. The use of standard scores allows the
observation of the children over the one year period
while they are growing. Figure 2 shows the BMI
expressed as standard scores at weeks 0, 8 and 52.
Figure 2 Standard scores for BMI of children weeks 0, 8 and 52.
International Journal of Obesity
Children's weight loss programme
PJ Gately et al
1450
These data illustrate population BMI at the 50th
percentile (0.00) the 85th percentile (1.00) and the
mean standard score at weeks 0, 8 and 52. During the
8 week intervention there was a signi®cant
(P ˆ 0.000) reduction in the mean standard score for
BMI (3.61 1.9 week 0 to 2.43 1.64 week 8).
During the follow-up period there was a non-signi®cant (P ˆ 0.071) increase in mean BMI standard score
(2.43 1.64 week 8 to 2.73 1.93 week 52). In
addition, the 44 week follow-up score for standardised
BMI was signi®cantly lower (P ˆ 0.000) than the
standard BMI score at week 0. The individual standard scores provide a similar picture to the other
forms of analysis, indeed, the analysis with standard
scores provide further positive data on the camp
programme and the 44 week follow-up period.
Figure 1 shows that, during the 44 week follow-up
period with respect to standardised BMI, 40% of the
subjects continued to reduce their standardized score
for BMI and 91% of the subjects had a lower standard
score for BMI at week 52 compared to week 0.
Discussion
Many studies have indicated that obesity is associated
with increased morbidity, mortality and a variety of
disease including coronary heart disease (CHD),
hypertension and diabetes.1,2 The Framingham study
has attempted to quantify the effect of a successful
reduction in body mass on these diseases. The results
suggested that heart disease could be reduced by 25 ±
35% if optimal weights were attained.1
It would seem that strategies such as dietary intervention, exercise and behavioural modi®cation all
contribute to short-term success in the treatment of
obesity.7 However, each has problems associated with
poor long-term success. Adopting a strategy which
uses these tools collectively may help address
the large reversal of body mass seen in many
programmes.
This study used an approach that involved a multifactorial strategy which included calori®c restriction,
physical activity, behavioural modi®cation and education. Furthermore, the physical activity programme
utilized differed greatly from previously reported
studies, as the camp programme incorporated a structured fun-based skill-learning approach to physical
activity and sport. The aim was to improve children's
skills in a variety of sporting situations so that they
would improve in self con®dence and performance
and therefore be more likely to maintain these activities when they returned to their normal environments.
This is different from conventional approaches which
have used exercise prescriptions based on ®xed intensity, duration and frequency and focused only on
reducing body mass.5,15,17,23 Such interventions may
have been unsuccessful because they did not teach
participants that physical activity, exercise and sport
International Journal of Obesity
can be fun and can be developed by the individual in a
variety of ways, thus empowering them to participate
more fully in recreational exercise and sport away
from the intervention situation. This is supported by
Dietz, who has suggested that `alternatives to the
conventional approach to therapy must be considered',24 and Epstein,17 who has suggested the reduction of sedentary behaviour rather than the adoption of
regimented physical activity as an important factor in
long term weight management.
Calori®c restriction in this study was not as severe
as in other studies, ie 1400 kcal=day in the present
study compared to 1000 kcal=day in Pavlou's study.15
This was an attempt to avoid the problems associated
with loss of lean muscle tissue and interference with
growth and maturation, which can occur with severe
calori®c restriction.43,44 The emphasis in this element
of the programme was to give children the necessary
nutrition for maintenance of their physical activity
together with the skills and understanding of portion
control to modify their energy intake on return to their
normal environment.
The mean reductions in body mass reported during
the 8 week programme are similar to those reported
during other studies. In a review by Miller20 mean
reductions in body mass were 11 kg for diet and
exercise programmes which averaged 13.4 weeks in
duration. This weight loss is similar to current study
where the mean reduction in body mass was 10.8 kg;
however, the duration of the present study was 8
weeks. Caution must be taken with this analysis as
the review by Miller was carried out on programmes
involving adults. Unfortunately, very little directly
comparable data exists on children's weight loss
programmes, so it is dif®cult to compare the outcomes
of this intervention with others. Researchers that have
reported success in the treatment of obese children
include: Epstein et al 45 used programmed exercise
and dietary restriction to obtain a signi®cant reduction
(P < 0.01) in BMI of 1.37 kg=m2 in a sample of obese
children during an 8 week programme; and Sasaki et
al 46 used dietary restriction and exercise during a 2 y
programme and noted signi®cant reductions
(P < 0.001) of 55% (boys) and 48% (girls) in obesity
index. Clearly differences in age of children, length of
programme, modality of programme and form of
assessment used, make direct comparisons between
these interventions dif®cult.
During the follow-up period in this study there was
a signi®cant increase (P ˆ 0.000) in mean body mass.
This was to be expected as subjects were unlikely to
fully maintain the levels of physical activity or dietary
restriction experienced on the camp programme and
also this is a time of rapid growth and development in
this age group. In spite of this, the mean BMI was
signi®cantly lower (P ˆ 0.000) at week 52 than at the
start of the programme.
Obesity has been de®ned as a BMI above the 85th
percentile for age and sex.27 ± 29 This de®nition was
used to produce standard scores so that the effects of
Children's weight loss programme
PJ Gately et al
growth may be quanti®ed. Figure 2 shows the change
in standardised BMI scores from weeks 0, 8 and 52.
There was a non-signi®cant difference between
body mass at week 0 and week 52, which illustrates
that overall the subjects did not gain extra body mass.
This is even more encouraging given there was a
signi®cant increase (P ˆ 0.000) in stature over the
same period.
These ®ndings were further supported when comparison was made with the NCHS data to illustrate the
expected change in body mass due to growth over this
period. This crude use of the NCHS data shows that
growth may account for as much as 65% in girls and
60% in boys of the total change in body mass during
the follow-up period. The comparison of change in
stature of the children and the NCHS data illustrate
that the change in the sample of boys is similar to the
change in NCHS reference data; however, the change
in stature of the sample of girls was higher than the
NCHS reference data. This greater change in stature
of the sample of girls may indicate the attainment of
peak height velocity during this period which would
have a favourable affect on the results. Unfortunately
there is no growth data available on these children
further than the 1 y period and the evidence that obese
children have different growth rates to the normal
population makes these results dif®cult to interpret.
Therefore, caution must be taken when viewing the
®ndings in this context. It should be noted these data
were used as an observation to illustrate that children's increased body mass may in part be attributed
to growth, rather than just their inability to manage
their body mass.
An important and interesting factor is the large
variation in the responses during the 44 week
follow-up period, when children were unsupported
and subject to a range of factors likely to in¯uence
their ability to maintain their reduced body mass
during the treatment period. The camp programme
can be seen to be successful given that 10% of
subjects continued to reduce body mass and a further
43% of subjects had a lower body mass than when
they enrolled on the programme. In addition, 26% of
the subjects reduced their BMI during the 44 week
follow-up. The variation in responses are important,
and may highlight the need for individualized support
during the follow-up period. Currently little data
exists with regard to how best to follow-up participants involved in interventions for the treatment of
obesity.
Overall there was an 6% increase in BMI during the
44 week period but 80% of subjects had a lower BMI
than when they enrolled on the camp programme.
When individualized standard scores are calculated a
similar picture is seen in the data. However, the
standard scores illustrate an improved analysis with
the data suggesting 40% of subjects continue to
reduce their standardised BMI during the 44 week
follow-up and 89% of subjects had a lower standardised BMI than at the start of the programme. In
addition, these data showed a non-signi®cant increase
(P ˆ 0.071) in the standardised BMI scores during the
44 week follow-up.
One obvious problem with the study design was the
absence of a control group. This poses a number of
problems with regard to generalising the results of this
intervention. However, this form of intervention presents problems with the assignment of a control group
due to it being a special residential programme.
Indeed, the multifactorial nature of this intervention
increases the problems experienced when trying to
control for the variety of changing variables.
Despite the lack of a control group, the problems of
controlling exactly for growth, and the lack of support
that is available to the children throughout the year,
the evidence presented here suggests that the camp
programme may have had some role in the maintenance of body mass over 1 y whilst the subjects have
continued to grow. Furthermore, BMI has reduced
over the same time period. It would appear that a
camp programme which concentrates on increasing
the skills associated with sports performance and
other recreational physical activities and not just on
reducing body mass, is to some degree successful in
producing some lifestyle modi®cations in the children.
Given the lack of support that exists for the 44 week
period these results are encouraging.
Further work is needed to establish some local
support in order to increase the likelihood of greater
success for long-term change. In addition, children
should be monitored during the follow-up phase to
investigate if they have employed lasting lifestyle
changes. It would also be useful to quantify the
improvements in sporting skills made by the children
so that valid statements can be made about the
improvements in their ability to perform sports in
their normal environments. Qualitative analysis is
required to identify any common factors in the
responses of the participants to the camp programme.
Finally, reference data for overweight and obese
children's growth patterns would be useful to enable
the assessment of treatments and long-term follow-ups
within this population. At present it is dif®cult to
quantify changes in this population as there is no
applicable data to measure treatments against. This
form of reference data would therefore be useful to
identify appropriate references of treatment and
change.
1451
References
1 Hubert HB, Feinleib M, McNara PM, Castelli WP. Obesity as
an independent risk factor for cardiovascular disease a 26 y
follow up of participants in the Framingham Heart study.
Circulation 1983; 67: 452 ± 458.
2 Sjonstrom LV. Morbidity of severely obese subjects. Am J
Clin Nutr 1992; 55: 508S ± 515S.
3 Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL.
Increasing prevalence of overweight among US adults. The
National Health and Nutrition Examination Surveys 1960 to
1991. JAMA 1994; 272: 205 ± 211.
International Journal of Obesity
Children's weight loss programme
PJ Gately et al
1452
4 Center for Disease Control. Update: prevalence of overweight
among children, adolescents and adults Ð United States,
1988 ± 1994. JAMA 1997; 277: 1111.
5 Cohen CJ, McMillan CS, Samuelson DR. Long-term effects of
a lifestyle modi®cation exercise programme on the ®tness of
sedentary, obese children. J Sports Med Phys Fitness 1991; 31:
183 ± 188.
6 Hagan RD, Upton SJ, Wong L, Whittam J. The effects of
aerobic conditioning and=or caloric restriction in overweight
men and women. Med Sci Sports Exercise 1986; 18: 87 ± 94.
7 Hill JO. The effects of exercise and food restriction on body
composition and metabolic rate of obese women. Am J Clin
Nutr 1987; 46: 622 ± 627.
8 Garner DM, Wooley SC. Confronting the failure of behavioural and dietary treatments for obesity. Clin Psychol Rev
1991; 11: 729 ± 780.
9 Wardle J. Obesity and behaviour change: matching problems
to practice. Int J Obes Relat Metab Disord 1996; 1: S1 ± S8.
10 Depres JP, Bouchard C, Savard A. The effect of a twenty week
endurance training programme on adipose tissue morphology
and lipolysis in men and women. Metabolism 1984; 33:
235 ± 239.
11 Bar-Or O, Foreyt J, Bouchard C, Brownell K, Dietz WH,
Ravussin E, Salbe AD, Schwenger S, St. Joer S, Torun B.
Physical activity, genetic and nutritional considerations in
childhood weight management. Med Sci Sports Exerc 1998;
30: 2 ± 10.
12 Brown MR, Klish WJ, Hollander J. A high protein, low calorie
liquid diet in the treatment of very obese adolescents: long
term effect on lean body mass. Am J Clin Nutr 1983; 38:
20 ± 31.
13 Prentice AM, Jebb SA. Obesity in Britain; gluttony or sloth.
Br Med J 1995; 311: 437 ± 439.
14 Bouchard C, Depres JP, Tramblay A. Exercise and obesity.
Obes Res 1993; 1: 133 ± 147.
15 Pavlou KN, Krey S, Steffee WP. Exercise as an adjunct to
weight loss and maintenance in moderately obese subjects. Am
J Clin Nutr 1989; 49: 1115 ± 1123.
16 Parker DL, Bar-Or O. Juvenile obesity. The importance of
exercise and getting children to do it. T Physician Sportsmed
1991; 19: 113 ± 125.
17 Epstein LH, Valoski AM, Vara LS, Mccurley J, Wisniewski L,
Kalarchian MA, Klein KR, Shrager LR. Effects of decreasing
sedentary behavior and increasing activity on weight change in
obese children. Health Psychol 1995; 14: 109 ± 115.
18 Ballor DL, Poehlman ET. A meta-analysis of the effects of
exercise and=or dietary restriction on resting metabolic rate.
Eur J Appl Physiol 1995; 71: 535 ± 542.
19 Garrow JS, Summerbell CD. Meta-analysis: effect of exercise,
with or without dieting, on the body composition of overweight subjects. Eur J Clin Nutr 1995; 49: 1 ± 10.
20 Miller WC, Koceja DM, Hamilton EJ. A meta-analysis of the
past 25 y of weight loss research using diet, exercise or diet
plus exercise intervention. Int J Obes Relat Metab Disord
1997; 21: 941 ± 947.
21 Ready AE, Fitzpatrick DW, Boreskie SL, Hrycaiko DW. The
response of obese females to low impact exercise and diet
counselling. J Sports Med Phys Fitness 1991; 31: 587 ± 595.
22 Armstrong N. The challenge of promoting physical activity.
J R Soc Health 1995; 6: 187 ± 192.
23 Malina RM. Tracking of physical activity and physical ®tness
across the lifespan. Res Q Exercise Sport 1996; 67: 48 ± 57
(Suppl 3).
24 Dietz WH. Therapeutic strategies in childhood obesity. Horm
Res 1993; 39: 86 ± 90.
25 Stark O, Atkins E, Wolff OH, Douglas JWB. Longitudinal
study of obesity in the national survey of health and development. Br Med J 1981; 281: 13 ± 17.
International Journal of Obesity
26 Freedman DS, Shear CL, Burke GL, Srinivasan SR, Webber
LS, Harsha DW, Berenson GS. Persistence of juvenile onset
obesity over eight years. The Bogalusa Heart study. AJPH
1987; 77: 588 ± 592.
27 Must A, Strauss RS. Risks and consequences of childhood and
adolescent obesity. Int J Obes Relat Metab Disord 1999; 23:
S2 ± S11.
28 Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Longterm morbidity and mortality of overweight adolescents.
New Engl J Med 1992; 327: 1350 ± 1355.
29 Epstein LH, Valoski AM, Wing RR, McCurley J. Ten-year
outcomes of behavioural family-based treatment for childhood
obesity. Health Psychol 1994; 13: 373 ± 383.
30 Epstein LH, McCurley J, Valoski A, Wing R. Growth in
obese children treated for obesity. Am J Dis Child 1990;
140: 1360 ± 1364.
31 Van Lenthe FJ, Kemper CG, Van Mechelen W. Rapid maturation in adolescence results in greater obesity in adulthood: the
Amsterdam Growth and Health Study. Am J Clin Nutr 1996;
64: 18 ± 24.
32 Fox K, Biddle S. The child's perspective in physical education. Part 2: Children's Participation Motives. Br J Phys Educ
1988; 19: 79 ± 82.
33 Gould D. Psychosocial development and children's sport. In:
Thomas JR (ed). Motor Development During Childhood and
Adolescence. Burgess: Minneapolis, MN 1984.
34 Wankel LM, Kreisel PS. Factors underlying enjoyment of
youth sports: sport and age group comparisons. J Sports
Psychol 1985; 7: 51 ± 64.
35 Thompson CE, Wankel LM. The effects of perceived activity
choice upon frequency of exercise behaviour. J Appl Soc
Psychol 1980; 10: 436 ± 443.
36 Lohman TG, Roche AF, Martorell R. Anthropometric Standardization Reference Manual. Human Kinetics: Champaign,
Il, 1989.
37 Guo SS, Roche AF, Chumlea WC, Gardner JD, Siervogel RM.
The predictive value of childhood body mass index values for
overweight at age 35 y. Am J Clin Nutr 1994; 59: 810 ± 819.
38 Hammer LD, Kraemer HC, Wilson DM, Ritter PL, Dornbusch
SM. Standard percentile curves of body-mass index for children and adolescents. Am J Dis Child 1991; 145: 259 ± 263.
39 Hamill PV, Drizd TA, Johnson CL, Reed RB, Roche AF,
Moore WM. Physical growth: National Center for Health
Statistics percentiles. Am J Clin Nutr 1979; 32: 607 ± 629.
40 Dietz WH, Robson TN. Assessment and treatment of childhood obesity. Pediat Rev 1993; 14: 337 ± 344.
41 Must A, Dallal E, Dietz WH. Reference data for obesity: 85th
and 95th percentiles of body mass index (wt=ht2) and triceps
skinfold thickness. Am J Clin Nutr 1991; 53: 839 ± 846.
42 World Health Organisation. Obesity, preventing and managing
the global epidemic. Report of a WHO consultation on
obesity. WHO: Geneva, 1997.
43 Rowland T. Exercise and Children's Health, 2nd edn. Human
Kinetics: Champaign, Il, 1990.
44 Saris W. The role of exercise in the dietary treatment of
obesity. Int J Obes Relat Metab Disord 1993; 17: S17 ± S21.
45 Epstein L, Wing RR, Koeske R, Ossip DJ, Beck S. A
comparison of lifestyle change and programmed aerobic
exercise on weight and ®tness changes in obese children.
Behav Ther 1982; 13: 651 ± 665.
46 Sasaki J, Shindo M, Tanaka H, Ando M, Arakawa K. A longterm aerobic exercise program decreases the obesity index and
increases the high density lipoprotein cholesterol concentration in obese children. Int J Obes 1987; 11: 339 ± 345.