Childhood and adolescent obesity program combines ‘body and soul’


Noa (not her real name) set the empty chair in the middle of the room opposite her own chair. On the seat, she placed some burekas (savory pastries) and then sat down. ” ‘You know she is addicted. She eats all the time,’ the burekas told one another.”

This was not a scene from a theater of the absurd. Rather, it is a young girl’s dramatic creation during a psychodrama workshop aimed at helping overweight youngsters come to terms with themselves, their weight and their feelings towards life and food.

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Noa is one of some 325 overweight children and adolescents who have been treated in the five years since the workshop was established by the Obesity Clinic of the Pediatric Endocrinology and Diabetes Unit at Israel’s largest medical facility, the Chaim Sheba Medical Center at Tel Hashomer. Set up as part of Sheba’s efforts to deal with one of the Western world’s fastest growing health problems — childhood and adolescent obesity — the clinic is the only one in Israel taking a comprehensive approach to the problem that combines both “body and soul.”

“I came here out of a belief that there was a need for another way to treat obesity in children and adolescents,” says Dr. Netalie Shalom, who coordinates the Obesity Clinic’s workshops and runs its special psychodrama workshop. “Dietary education and sports are not enough. Only a comprehensive approach that also works on providing psychological support can help these children succeed. For that reason, the treatment center includes not only nutrition and exercise programs but also psychodrama, movement therapy, a cooking workshop, a summer camp and support hotline. Our multidisciplinary staff includes dietitians, social workers, physical education teachers, psychologists, endocrinologists, physicians, etc.”

For children and adolescents, overweight is defined as having a BMI (body mass index) heavier than 85 percent of those of the same age and sex. Obesity is defined as a BMI heavier than 95 percent.

According to a study carried out in 2004 by the Atlanta-based U.S. Centers for Disease Control and Prevention, some 34 percent of U.S. children met the criterion for overweight or more. In Israel, the number of overweight teens is estimated to be 12 percent and obese teens 4 percent. These figures are based on examinations conducted by the Israel Defense Forces on 16- and 17-year-olds to determine fitness for military service.

“The problem in Israel is still not as severe as in the US,” states Dr. Orit Pinhas-Hamiel, director of the Pediatric Endocrinology and Diabetes Unit, “but it is increasing and getting worse from year to year.”

As a hospital clinic, the Obesity Clinic sees children up to the age of 18 who have been referred to it by their health funds. Most have not succeeded in dealing with their weight problems in other frameworks. The children come once a week, for half a day to participate in an intensive, comprehensive program of nutrition, exercise and support.

“We treat extreme cases,” explains Pinhas-Hamiel. “Our patients are not just five or even 10 kilos overweight. They are what we call morbid obese. That means that they are either extremely fat or are suffering from medical complications. We have had children who weighed as much as 150 kilos. We have also treated patients as young as three years old. Some of our children have orthopedic problems, including knee and lower back pain, caused by their weight. We also see kids suffering from secondary health complications that we once only associated with adults — such as hypertension, type II diabetes, high cholesterol and sleep apnea. These children are at serious risk of developing cardiovascular disease, as well as certain types of cancer. And believe me there is a big difference between developing these conditions at age 10 instead of at age 50. The long-term health prognosis for such children is very frightening.”

The unit was set within Sheba’s pediatric endocrinology department because, as Pinhas-Hamiel notes, “every parent of an overweight child thinks he or she has a hormone problem. But in fact less than 2 percent of childhood and adolescent weight problems are caused by medical (organic) reasons. Some 98 percent of the cases are caused by a combination of genetics and lifestyle. We can’t do anything about genetics, so we concentrate on working on lifestyle.”

Pinhas-Hamiel is critical of the fact that today’s children are more sedentary than a generation ago. “Children generally come home from school and stay at home,” she notes. “They don’t go out to play in the street anymore. I understand that parents are often at work and are afraid to let children out because of crime and terrorism. So kids sit in front of the TV or the computer. There is a correlation between overweight and the number of hours spent watching TV. And while they are watching TV, they see ads for junk food. In addition, since parents are at work, many children have to prepare their own meals. So they eat what is easiest to prepare and not necessarily what is healthiest for them.”

Every child who comes to the Obesity Clinic first undergoes a complete medical check up to determine if there are organic reasons for his or her weight and to see if there are any secondary health complications. After that, the staff builds an individual program for the child. The clinic also works extensively with parents, especially in the case of very young patients.

“There are special considerations in treating children and adolescents,” says Pinhas-Hamiel. “Since they are still growing, the goal, in most cases, is to keep them from gaining weight rather than losing it. Also, children and adolescents need diets that do not adversely affect their growth and development. They can’t fast or do extreme diets. They have to have diets that include the whole spectrum of vitamins and minerals needed for proper growth.”

In addition to its medical implications, overweight has numerous psychological ones as well.

“Most of our children experience great distress stemming from their weight,” Shalom relates. “They feel different wherever they go. They are taunted and bullied. For many, when they come here, it is the first time that they feel among equals. Using psychodrama, a form of therapy in which patients create and act out scenes, we work to strengthen their sense of empowerment and self-worth, and to show them that there are healthier ways to cope with stress and disappointment than eating.”

The clinic runs 10 psychodrama workshops for 100 participants ranging in age from six to nearly 18. Because the Sheba Medical Center is located near Bnei Brak, some of the psychodrama groups cater especially to children from the ultra-Orthodox population and have even received rabbinical approval.

“Most of the kids have tried and failed at all kinds of diets,” Shalom adds. “They don’t want to hear about food. This is very threatening for them. Psychodrama lets them do something else, something that is fun. We give them a safe environment in which they can express anything they want. And something wonderful happens — they begin to heal. Only when they start to see their self-worth and power, can they begin to change.”

Dina (not her real name) began coming to the psychodrama workshop at age 12. She was extremely shy and lacked self-confidence. In addition, she felt she had no friends because of her weight.

Today, Dina is 17 and is a different person. She is outgoing, has lots of friends and feels really good about herself. Moreover, she has succeeded in losing weight and is now almost down to what is considered normal. “The workshop helped me tremendously,” she insists. “Yes, there were ups and downs but the group was always there for me.”

“I don’t want to say that every case has a happy ending,” says Shalom. “There are children who don’t succeed in losing weight. But I believe that those who try hard and commit themselves to the process succeed. They may not lose weight but they will finish the program with a better body image and greater self-confidence. Psychodrama is not a miracle cure, and the treatment is long, slow and often frustrating. But those who stick it out for the long term, experience significant changes that enable them to lose weight and keep it off.”