Cecilia Moore, MS, RD, LDTTUHSC Department of Pediatrics

Lubbock, Texas

Objectives

Identify at least 2 major lifestyle contributors to overweight/obesity in the pediatric population 2-19 years of age.

Evaluate the pros vs. cons of the clinical setting using data from the TTUHSC Healthy Kids program.

Compare the pros vs. cons of the school-based setting as an intervention

Prevalence of Obesity* Among U.S. Children and Adolescents(Aged 2 –19 Years)National Health and Nutrition Examination Surveys

Data from NHANES I (1971–1974) to NHANES 2003–2006 show increases in overweight among all age groups: Among preschool-aged children, aged 2–5 years, the prevalence of obesity increased from 5.0% to 12.4%.8, 46 Among school-aged children, aged 6–11 years, the prevalence of obesity increased from 4.0% to 17.0%.8, 46 Among school-aged adolescents, aged 12–19 years, the prevalence of obesity increased from 6.1% to 17.6%.8, 46

The 2007 national Youth Risk Behavior Survey indicates that among U.S. high school students:

Overweight 13% were obese.

Unhealthy Dietary Behaviors 79% ate fruits and vegetables less than five times per day

during the 7 days before the survey. 34% drank a can, bottle, or glass of soda or pop (not

including diet soda or diet pop) at least one time per day during the 7 days

before the survey. Physical Inactivity

65% did not meet recommended levels of physical activity. 46% did not attend physical education classes.70% did not attend physical education classes daily. 35% watched television 3 or more hours per day on an average school day. 25% played video or computer games or used a computer for 3 or more hours per day on an average school day.

Reasons for the Prevalence of Childhood ObesityGenetic predisposition: Twin studies estimate that 65%

to 75% of the tendency to obesity is inherited. Heritability of obesity greater than schizophrenia, alcoholism and atherosclerosis. Inheritance is mostly polygenic and varies.

Weight Set Point HypothesisEvery individual has a genetically inherited “set point ” that governs “ideal” body mass.Environmental factors influence this set point and determine actual body mass.

Environmental influences:

Availability of high caloric density, palatable food. Since the early 1900’s consumption of fats and sugars increased by 67 and 64%, vegetables decreased by 26%.

Advertising to children. On average a child sees 10,000 ads a year and 90-95% are for sugared cereals, fast food, soda, candy

Portion Distortion: Serving Sizes are GrowingSeveral studies published in 2003 document increases in portion sizes for many popular foods. This amounts to an additional 50-150 calories per meal.

Movement Towards a More Sedentary Lifestyle

Serving Sizes Then and NowFood or beverage

1950s Expanded 2003 French fries   2.4 ounces   up to 7.1

ounces Fountain soda   7.0 ounces   12 to 64

ounces Hamburger patty   1.6 ounces   up to 8.0

ounces Hamburger sandwich   3.9 ounces   4.4 to 12.6

ounces Muffin   3.0 ounces   6.5 ounces Pasta serving   1.5 cups   3.0 cups Chocolate bar   1 ounce   2.6 to 8 ounces

Rate of weight gain due to “extra” calories

Rate of weight gain when calories consumed equals

calories required for normal growth and development.

50 calories per day over daily requirement

100 calories per day over daily requirement

IS OBESITY A DISEASE IN CHILDHOOD?Obesity is associated with insulin

resistance and metabolic syndrome

65% of obese 5-10 year old children have at least 1 cardiovascular disease risk factor hypertension, hyperlipidemia,

abnormal glucose tolerance

25% of obese 5-10 year old children have 2 or more risk factors

Dietz WH.JPediatr1999;134:535-536

Obesity: other associations and complications

Obstructive sleep apnea Fatty liver disease with steatosis (NAFLD, NASH) Orthopedic problems (SCFE, osteoarthritis) Hypertension, pulmonary hypertension GERD Diabetes Pubertal disorders Chronic kidney disease Polycystic ovary syndrome

Changing the Incidence of Childhood Obesity - Society?

Very hard to effect “global change” when a majority of the population either is not at

risk or doesn’t perceive it as “their problem”.

How can we outlaw video games when we can’t even regulate more “obvious” health

risks like cigarettes, and alcohol?

Pediatric Weight Loss Programs in CommunityMostly hospital, or clinic-based. Some are

franchised, for fee.Education on healthy eating, parenting, behavioral

modificationVariable duration, curriculaHigh attrition rates (50-60%)Lack of published data on effectiveness of

interventionMost do not involve significant exercise

component (lack of resources, liability issues)Limited evidence of sustainability of weight lossExpensive

Taking a look at a clinical intervention: Healthy Kids ClinicHealthy Kids (overweight/obesity) clinic

Texas Tech University Health Sciences Center Department of Pediatrics

Lubbock, TXEstablished in 2006Purpose: to provide a clinical approach to

the childhood obesity epidemic in the area

Multidisciplinary TeamPediatrician/Pediatric EndocrinologistRegistered DietitianPsychology graduate studentExercise & Sports Sciences graduate student

Original PlanAppointments upon referral1st visit: meet entire team for assessment Bi-monthly follow-up visits with RD, and

psychologyExercise opportunities twice a weekFollow up visits with MD every 3 monthsProvide an individualized plan to aid in

weight control and implement healthy lifestyle changes for the entire family

Issues along the wayMOTIVATION!Bi-monthly visits Follow-up visits with MDSchedulingGraduate students – new students, new

training, different experiencesChanges with the exercise portion of the

intervention – TTU Recreation Center, Fitness and Wellness

Clinic Trends: 2008-2009Collected data for 2 yearsTotal referrals to Healthy Kids 2008: 130Total referrals for 2009: 138~85% from Lubbock area

~15% from surrounding area

Percentage of referrals from different age groups

About 8 % of our referrals were siblings in 2008, and 5% in 2009.

Referrals: Gender

Ethnicity: Comparison of 2008-2009

Referrals: Ability to Schedule

Show Rate: Initial Visit

Follow-up rate

Weight TrendsRandomly looked at 70 patients100% of those seen at their initial visit had

BMI’s > 95th percentile (highest: 53.8 kg/m2, 15 yo female, 51 kg/m2 17 yo male

Success is individualized based on:Age: weight loss vs. weight maintenanceBMI trendsCompliancy with goals: were we able to make

some progress with changing lifestyle habits? Improvement in labs

Trends cont…About 20% of this group had some sort of

success at some pointHowever, about 21% of these patients, when

last seen, had an increase in BMI Weight loss/maintenance was seen more in

those who visited once every 1-2 monthsWhen more time lapses between visits =

more weight gain!

IssuesIndividualized vs. group?MOTIVATION!

Assessment of readiness-to-change is not occurring at pediatrician’s office first

Patience – takes time to get to goalScheduling issues

Clinic daysAppointment times availableIssues with the routine of how appointments are

scheduled Location/setting

PositivesMultidisciplinary teamIndividualizedEmphasizes family supportAbility to recommend other subspecialty

referralsAn option that can work for some

The School Health Policies and Programs Study 2006 indicates that among U.S. high schools:

Health Education • 69% required students to receive instruction on health topics as part of a specific course. • 53% taught 14 nutrition and dietary behavior topics in a required health education course. • 38% taught 13 physical activity topics in a required health education course.

Physical Education and Physical Activity •95% required students to take physical education; among these schools 59% did not allow students to

be exempted • 2% required daily physical education or its equivalent for students in all grades in the school for the

entire year. •45% offered opportunities for students to participate in intramural activities or physical activity clubs.

School Environment • 18%, students could purchase fruits or vegetables. • 77%, students could purchase soda pop or fruit drinks that are not 100% juice. • 50%, students could purchase chocolate candy. • 52% did not allow students to purchase foods or beverages high in fat, sodium, or added sugars

during school lunch periods.

Nutrition Services • 77% offered a choice between 2 or more different fruits or types of 100% fruit juice each day for

lunch. • 49% did not sell any fried foods as part of school lunch. • 81% offered lettuce, vegetable, or bean salads a la carte

Role of Schools in Preventing ObesitySchools are a critical part of the

social environment that shape children’s eating and physical activity patterns

Lead by example: healthy food served while at school, and limited access to “junk food”

Provide access to and maintain healthy amount of physical activity while at school

Widen the school-home collaboration to promote child’s physical health and fitness

Percentage of secondary schools in which students could not be exempted from taking required physical education for certain reasons*

*Enrollment in other courses, participation in school sports, participation in other school activities, participation in community sports activities, high physical fitness competency test score, participation in vocational training, and participation in community service activities.

14% - 50%

51% - 71%

72% - 79%

80% - 96%

No Data

School Health Profiles, 2008

Percentage of secondary schools in which students could not purchase other kinds of candy from vending machines or at the school store, canteen, or snack bar

23% - 63%

64% - 71%

72% - 83%

84% - 95%

No Data

School Health Profiles, 2008

Percentage of secondary schools in which students could not purchase salty snacks that are not low in fat* from vending machines or at the school store, canteen, or snack bar

*Such as regular potato chips.

28% - 57%

58% - 64%

65% - 76%

77% - 91%

No Data

School Health Profiles, 2008

Percentage of secondary schools in which students could not purchase soda pop or fruit drinks that are not 100% juice from vending machines or at the school store, canteen, or snack bar

26% - 51%

52% - 62%

63% - 73%

74% - 93%

No Data

School Health Profiles, 2008

School-Based InterventionsBoarding schools (Wellsprings

Academy) and Summer camps (“fat camps”): very effective, but not feasible for mainstream

School-based nutritional education programs

Gaining popularity, however greatly variable duration and curriculums

Published studies use BMI as outcome measure

Most show none or modest improvements in weight, BMI

Some show improved dietary habitsLittle data on sustainabilityBelieved to be more effective than

the hospital-based programs due to peer participation

P-value

Control (n=123) Intervention (n=109) Mean Delta BMI Z 0.0364 -0.0588 p<0.0001

Std. Dev. 0.1664 0.1688

P-value

Control (n=61) Intervention (n=57)Mean Delta BMI Z 0.0062 -0.0349 p=0.0185

Std. Dev. 0.0991 0.0915

P-value

Control (n=46) Intervention (n=44)Mean Delta BMI Z 0.0148 -0.0413 p=0.0022

Std. Dev. 0.0925 0.0837

TABLE I. CHANGE IN BMI Z SCORE OVER 6 WEEKS

All Children (n=232)

Children with BMI percentile ≥ to 85% (n=118)

Children with BMI percentile ≥ to 90% (n=90)

Methods The study took place over the 2006-2007 school year

at 8 matched elementary schools in low-income school districts in Los Angeles, San Jose, and Vacaville CA.

Population consisted of 325 child participants and 229 parents, of which full data was collected on 232 children.

Of these 232 individuals, 109 were in the intervention group and 123 were in the control group.

Families at the intervention schools attended 6 weekly 3-hour classes consisting of didactic and interactive nutrition education, exercise, parental support and behavior change motivation.

Control schools families were tracked throughout the year for comparison.

Adiposity measures, nutrition knowledge and eating and physical activity behavior were measured.

Results Overall students in the intervention group showed a

significant 6-week decrease in BMI z-score compared to the control group, and a downward trend for body fat percentage.

Neither the effect of intervention on decrease in BMI z-score nor the downward trend for body fat percentage in the intervention was affected/altered by adjustment for age, gender, or school location.

 

Why schools?Other than families, many aspects about the

education setting have a large influence on children’s lives

Majority of time during the day is spent at school1-2 meals are provided

1-2 snacks

Where they will get their first official lesson on health, nutrition, and physical activity

IssuesFundingAdequate staffFood production contractsMedical issues of the individual might be

missedOthers?

Obesity Treatment: Basic ModalitiesLifestyle intervention: utmost importanceClinical vs. school setting interventions

Along with community assistanceMedical therapies: reserved for severe

obesity, very limited pharmacological agents available for children. Effective but results not sustainable

Surgical treatment in cases with poor prognosis in older adolescents