Childhood Obesity and the Childhood Obesity and the Modern Lifestyle: Modern Lifestyle:

Implications for Future Implications for Future GenerationsGenerations

“I think we’re looking

at a first generation of

children who may live

less long than their

parents as a result of

the consequences of

overweight and type 2

diabetes.”

Francine Ratner Kaufman, MD

Head, Division of Endocrinology & Metabolism

Children’s Hospital Los Angeles

www.discoveryhealthCME.com

Definition of ObesityDefinition of Obesity

•A chronic preventable disease

• Obesity is defined as excess body fat (not simply excess weight)

Definition of ObesityDefinition of Obesity

• BMI - Body Mass Index = weight/(height)(height)

• Adult definitions: – Overweight - BMI 25-29.9– Obesity - BMI > 30

• Children definitions: – Overweight - BMI for age >95th %ile – At risk for overweight - BMI for age >

85th %ile

Calculating Body Mass Index (BMI)Calculating Body Mass Index (BMI)

BMI (English): [ weight (lb) / height (in) / height (in) ] x 703

BMI (metric): [ weight (kg) / height (cm) / height (cm) ] x 10,000

BMI Conversion Tables: http://www.cdc.gov/Web Calculator: http://www.cdc.gov/Palm Calculator and Growth Chart: http://www.pdacortex.com/BMI Calculator Wheel: http://www.trowbridge-associates.com/ $5

REGIONAL HEALTH EDUCATIONREGIONAL HEALTH EDUCATION

BMI = 28

BMI Does Not Measure Body Fat

Percentage of Overweight Percentage of Overweight ChildrenChildren

and Youth who Become Obese and Youth who Become Obese AdultsAdults

Preventive Medicine 1993; Vol. 22:pp. 167-177Arch Pediatr Adolesc Med Vol. 158 May 2004 pp. 449-452

10

35

50

80

0102030405060708090

100

%

Infa

nts

Presc

hool

Schoo

l Age

Adolesc

ent

S Gee, Kaiser Permanente

Obesity Associated Obesity Associated Morbidity in ChildhoodMorbidity in Childhood

• Hypertension (9X risk compared to non-obese)

• Dyslipidemia

• Gall bladder disease

• Polycystic ovarian syndrome

• Fatty liver

• Early menarche

Pediatrics 1998; 102(3)

Obesity Associated Obesity Associated Morbidity in ChildhoodMorbidity in Childhood

• Type 2 diabetes of childhood/IGT or Pre-diabetes • Independent risk factor for early CV disease• Peer teasing/poor self esteem/depression/ negative self image and eating disorders• Obstructive sleep apnea – in about 7% of obese

children• Higher prevalence of moderate to severe asthma in

overweight children and adolescents• Ortho—slipped capital femoral epiphysis, Blount’s

disease, osteoarthritis of the knees, weight stress on growth plates of lower extremities (pain & decreased ROM)

O b e s i t y a n d D i a b e t e s R i s k

01 02 03 04 05 06 07 0

< 2 0 2 0 - 2 5 2 5 - 3 0 3 0 - 3 5 3 5 - 4 0 > 4 0

B M I

O b e s i t y a n d D i a b e t e s R i s k

K n o w l e r , W . C . ; A m J E p i 1 9 8 1

1 5 X

Metabolic Syndrome among Metabolic Syndrome among Overweight Children and Overweight Children and

AdolescentsAdolescents• Metabolic Syndrome (1)

Criteria: TG>=110 mg/dL, HDL-C<=40 mg/dL, Waist Circ. >=90%, FBS>=110 mg/dL, BP>= 90% (3 of 5 criteria needed)

Prevalence = 28.7% among overweight adolescents.

• The prevalence of metabolic syndrome increased with the severity of overweight and reached 50% in severely overweight children. (2)

1. Arch Pediatr Adolesc Med Vol. 157, Aug 2003 pp. 821-827

2. N Engl J Med Vol. 350, June 2004 pp. 2362-2374

Epidemiology of Overweight Epidemiology of Overweight in Kidsin Kids

in General U.S. Population in General U.S. Population

Preliminary data collected between 2000-2004 from the Preliminary data collected between 2000-2004 from the Nutrition Education Nutrition Education Needs Assessment SurveyNeeds Assessment Survey (NENAS) conducted in the public schools every ten (NENAS) conducted in the public schools every ten years shows an overweight problem among youth and teenagers:years shows an overweight problem among youth and teenagers:

‘At risk’ for overweight

Overweight Total

4th graders 15.7% 20.2% 35.9%

High school students

17.8% 18.9% 36.7%

Recent research studies suggest that Hawaii has a significant problem with childhood obesity.

A cross-sectional study of more than 20,000 children aged 2-4 years participating in the Hawaii WIC program in 1997-98, found that the prevalence of

overweight in all ethnic groups was above the expected 5% (Baruffi et al., 2004).

Ethnic Variation in Prevalence of Overweight Ethnic Variation in Prevalence of Overweight Among WIC ChildrenAmong WIC Children

Multivariate analysis showed that ethnicity had a strong independent association with BMI and overweight.

Children 2-4 years, Hawaii WIC program, 1997-98 % overweight

Asian 9.0

Black 7.3

White 8.5

Filipino 12.4

Hawaiian 11.3

Hispanic 10.1

Samoan 27.0

Other 11.9

Total 11.4

Trend data: Percent of children > 2 years at risk for and overweight, WIC program, 1991-2002

6.2 7.1 7.49 8 9.4 10.3 10.4 10.4

9.510.6 11.3

12.611.9

1313.7 13 13.8

5.6

10.3

7.8

13.4

0

5

10

15

20

25

30

1991 1992 1993 1994 1995 1996 1997 1998 2000 2001 2002

% over weight % at risk for over weight

Assessment of Height and Weight (BMI) Among Public School Students Entering Kindergarten, 2003-2004

By the State Department of Health

Methods

Retrospective record review of school health records:

• 12,682 children were enrolled in kindergarten in the DOE for the 2002-2003 school year.

• 12,240 Student Health Records were available for review.

• 10,676 records had complete data for age, sex, weight and height.

• 145 records with miscoded entries or implausible values for height and weight were omitted based on CDC criteria.

• 986 pre-kindergarten students with completed records were omitted from this study.

Results of kindergarten assessment:

A large proportion of Hawaii 4 & 5 year olds enter public schools with weight problems:

•14 % Overweight •15% ‘At-risk’ for overweight •29% Combined ‘at–risk’ and overweight

Adult Weight Surveillance Methodology

The Behavioral Risk Factor Surveillance System, a population based telephone survey conducted in Hawaii and throughout the U.S. reports rates of overweight and obesity among adults.

The BRFSS is an annual telephone survey of adults 18 years and older, which assesses the risk for chronic diseases, injuries and other health risk factors.

In the BRFSS, BMI is calculated based on self-reports of height and weight status.

Percent obese among adults 20 years or older by Ethnicity, Hawaii BRFSS combined year data set, 2000-2003

(age-adjusted)

61.3

35.3 30.9 28.3 28.020.7

14.1 11.0 10.5 10.019.2

4.70.05.0

10.015.020.025.030.035.040.045.050.055.060.065.070.075.080.085.090.095.0

100.0

Pe

rce

nt

Why is childhood obesity Why is childhood obesity increasing?increasing?

• Many theories:– Decrease in physical activity with less

opportunities for recreational activities for children and young adults/Increasingly sedentary life style

– Increase in availability and consumption of dense caloric foods

– Lower incidence of breastfeeding– In utero effects of diabetes

SupersizingSupersizingSupersizingSupersizing

“Old Days”HamburgerHamburger

280 kcal

Double Whopper with CheeseDouble Whopper with Cheese

1120 kcal

Increased CaloriesIncreased CaloriesIncreased CaloriesIncreased Calories

Classic CokeClassic Coke8 fluid oz8 fluid oz

100 kcal

100 kcal1950

1950

Extreme GulpExtreme Gulp52 fluid oz52 fluid oz

20022002

630 630

kcalkcal

MVPA* > 20 min in PE class

1991- 34.2%

1997- 21.7%

Less Physical Activity for Less Physical Activity for KidsKids

*Activities that caused sweating and hard breathing for at least 20 minuteson 3 or more of the 7 days precedingthe survey.

TV and ObesityTV and Obesity

• Multiple U.S. and international studies

• Increased TV viewing time associated with increased weight

• Causes?– Increased sedentary activity– Increased calorie consumption

• snacking while viewing• effect of commercials on food selection

Childhood OverweightChildhood OverweightFamily Risk FactorsFamily Risk Factors

One obese parent (3X

increase)

Two obese parents (13X

increase)

Early pubertyPediatric Overweight: A Review of the LiteratureThe Center for Weight and Health College of Natural ResourcesUniversity of California, Berkeleyhttp://www.cnr.berkeley.edu/cwh/PDFs/Full_COPI_secure.pdf

Overeating and Overeating and Psychological Psychological

DistressDistress““Youths who overeat may have or be at Youths who overeat may have or be at risk for serious psychological distress, risk for serious psychological distress,

including deficits to self-esteem, including deficits to self-esteem, compromised mood, and suicide risk. compromised mood, and suicide risk. Overeating may be a tangible behavior Overeating may be a tangible behavior that signals the need for intervention.”that signals the need for intervention.”

Ackard Ackard et alet al, , PediatricsPediatrics 2003;111:67-74 2003;111:67-74

Depression and Depression and ObesityObesity

““Depressed adolescents are at Depressed adolescents are at increased risk for the increased risk for the

development and persistence development and persistence of obesity during of obesity during adolescence.”adolescence.”

Goodman and Whitaker, Goodman and Whitaker, PediatricsPediatrics 2002;109:497- 2002;109:497-504504

““Depression duringDepression during childhood childhood is positively associated with is positively associated with

BMI during adulthood.”BMI during adulthood.”Pine Pine et al, Pediatricset al, Pediatrics 2001;107:1049-56 2001;107:1049-56

Lower Childhood Lower Childhood SES and Insulin SES and Insulin

ResistanceResistance

““Adverse social circumstances in Adverse social circumstances in childhood, as well as adulthood, childhood, as well as adulthood, are strongly and independently are strongly and independently

associated with increased risk of associated with increased risk of insulin resistance and other insulin resistance and other

metabolic risk factors.”metabolic risk factors.”

Lawlor Lawlor et al,et al, BMJ 2002;325:805BMJ 2002;325:805

“Growing up in such conditions could teach the child of parents with lower SES that the world is a hostile, depressing, and alienating place, and the child could also learn that smoking and consumption of larger amounts of alcohol and food help reduce the resulting distress.”

Redford Williams, JAMA 1998;21:1746

What the Medical Community Can Do

• Implement BMI screening and waist circumference screening for all patients.

• Promote the use of national guidelines and standard protocols by health care providers for the management of obesity.

• Assess co-morbidities.• Raise the issues of overweight or obesity, or

inappropriate weight gain even when overweight is not present.

Who needs medical intervention?

Sarah E. Barlow and William H. Dietz, Obesity Evaluation and Treatment: Expert Committee Recommendations, Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29

Treatment GoalsTreatment Goals

• Attain skills for a lifetime of weight management– self monitoring of eating, physical activity

and weight– social and emotional support– continued contact with the treatment team

• Realistic Weight Goal (may differ from that initially expressed by the teen or parents)

• For many, allow to grow into one’s weight (i.e. weight maintenance)

Treatment PrinciplesTreatment Principles

• Health promotion is the primary goal (NOT dieting)

• Family, not the child or teen, is identified as the patient

Recommended Weight GoalsRecommended Weight Goals

Weight loss approx. 1 pound/month

Weight goal: BMI< 85%

Sarah E. Barlow and William H. Dietz, Obesity Evaluation and Treatment: Expert Committee Recommendations, Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29

Summary Points for Summary Points for Management of Childhood Management of Childhood

OverweightOverweight

• Obesity may be genetic or endocrine• Be aware of its complications in children • Instilling healthy eating habits is better than restricting

diet• Sustainable lifestyle activities should be encouraged• Psychosocial problems are important consequences of

overweight or obesity• Behavioral treatments should be individually designed• All treatments must be acceptable to the family• Pediatrics July 2004;114:217–223

Calculate and plot BMI once a year in all children and adolescents.

Encourage and support breastfeeding. Encourage parents to promote healthy

eating patterns. Routinely promote physical activity. Recommend limitation and television

and video time to a maximum of 2 hours per day.

Recognize and monitor changes in obesity-associated risk factors for adult chronic disease.

Prevention of Pediatric Overweight and Prevention of Pediatric Overweight and ObesityObesity

American Academy of Pediatrics Policy American Academy of Pediatrics Policy StatementStatement

Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

Individual – Pub. Ed.Individual – Pub. Ed.

Social Norms – Pub. Ed.Social Norms – Pub. Ed.

Social Professional – Social Professional – Teaching & Prof. Ed.Teaching & Prof. Ed.

Policy/Structure/Environment - SchoolsPolicy/Structure/Environment - Schools

Policy/Structure/EnvironmentPolicy/Structure/Environment- Communities- Communities

Policy/Structure/Environment – Policy/Structure/Environment – County/StateCounty/State

Public Health Response: Social-Ecological Model (CDC)

Policy, Structure, EnvironmentPolicy, Structure, EnvironmentCommunitiesCommunities

• Promoting walkable communities

• Introducing workplace wellness initiatives and incentives

• Developing teams at worksites and communities throughout the state

• Supporting the Kaua‘i Great Weigh Out that included nutrition education classes, incentives and team physical activity events

Social NormsSocial NormsPublic EducationPublic Education

• Media: TV, Radio, Theaters, Print

• Partnerships & Special Events

• Website: www.HealthyHawaii.com

Policy, Structure, EnvironmentPolicy, Structure, EnvironmentSchoolsSchools

• Coordinating school health across components

• Supporting healthy food options during school hours

• Promoting access to physical activity and physical education

• Supporting health education and PE requirements and infrastructure

Examples of food policy changes Examples of food policy changes to reduce childhood obesityto reduce childhood obesity

• Eliminate access to “junk food” in elementary schools during the daytime (e.g. vending machines, canteens, fund-raising booths, etc.)

• Require that where vending machines, etc are present in middle and high school, that fruits and vegetables be offered in these settings

• Require closed campus during lunch in elementary and middle schools

• Prohibit schools from using junk food coupons as a reward for students

• Prohibit schools from displaying advertisements promoting junk foods, including on vending machines

• Require school food service managers be well trained

Knehans, A.W.; J OSMA 95(8),2002

Schools and Physical Schools and Physical ActivityActivity

• One additional hour of physical education in first grade compared to kindergarten reduces BMI among girls who were overweight or at risk for overweight in kindergarten. Am J Public Health Vol. 94 September 2004, pp. 1501-1506

Social ProfessionalSocial ProfessionalTeaching and Professional EducationTeaching and Professional Education

• Public health workforce development in core competencies

• Grade K to 12 teacher trainings in health education and physical education

• Summer graduate courses for teachers

• Some school based interventions have demonstrated improvements in physical activity, TV viewing, food choices and BMI.

• Advantages include:• Addresses all children not just

overweight.• Captive audience.• Lower costs when compared to clinical

programs and possibly cost-effective*.

• Disadvantages include:• In some cases less effective compared to

clinical programs with regard to behavior change and BMI improvement.

• Lack of parent involvement and behavioral therapy.

School Based Weight Management School Based Weight Management InterventionsInterventions

* Obesity Research. 2003;11:1313-1324

Barriers to CareBarriers to Care• Dysfunctional family situation• Medical model – individual patient vs.

family focus• Environmental obstacles: lack of transpor-• tation, limited access to healthy foods• Specific cultural issues, including beliefs

about diabetes• Eating and mood disorders, life stresses,

low self-esteem• Lack of appropriate role models• Lack of cultural sensitivity among health

care providers

Goals:1. Increase access to healthy

foods.2. Increase opportunities for physical

activity for Head Start children, parents, staff and communities.

3. Mobilize the communities on health promotion through local partnerships and local capacity building.

4. Promotion of healthy lifestyles through advocacy for policy change & dissemination of promising practices.

SummarySummaryGood News/Bad NewsGood News/Bad News

• Weight loss/ weight maintenance and effective treatment of type 2 diabetes in childhood and adolescence IS possible

• Childhood obesity/type 2 diabetes has taken priority in many research venues

• …and in local and national health programs

• …emphasis on prevention is gaining momentum

• It’s not easy • Drop out rates are high• Magnitude of type 2 diabetes

for all children is expected to increase

• There are multiple barriers to effective treatment/ prevention

• Hospital costs for childhood obesity-related diseases have tripled in the past 20 years ($35M to $127M in 1999)*

• Hospitalizations for obesity tripled, for diabetes doubled and for sleep apnea increased 5X in the past 20 years*

*Pediatrics, May 2002

• Childhood overweight and Type 2 diabetes are emergent public health concerns

• Magnitude of type 2 diabetes in all children is expected to increase

• Recognize children at risk of becoming overweight and obese early

• Recognize, treat and prevent adverse childhood experiences

• Become involved in developing and implementing school- and community-based programs to promote self-esteem, coping and behavior skills, and improved dietary and physical activity for all children and their families

Implications for Future Research

(1) Hawaii provides a unique opportunity to do more research about BMI measurement issues among Pacific Islanders and Asians;

(2) Providers need to acknowledge that cultural norms about body size exist among many Asian and Pacific peoples;

(3) We do not know enough about what different populations in Hawaii think of “obesity” (a western medical term) or body size relative to health;

(4) We need to find culturally appropriate ways to work with all diverse groups regarding achieving a healthy weight.

MAHALO TOMAHALO TO

• Chiyome L. Fukino, MD, Director of Health

• Kelly Moore, MD, FAAP, IHS Division of Diabetes Treatment and Prevention

• Margaret West, MPA, Dept. Native Hawaiian Health, UH JABSOM

Study population for kindergarten assessment

N=9,804 eligible and complete records.

Age ranged from 48 to 71 months (4-6 years).

The mean age was 57 months.

EpiInfo 2000 NutStat was used to calculate percentiles for BMI (body mass index), height for age and weight for height, which uses the 2000 CDC reference population.

31.928.9

24.0 22.920.7 19.9 18.5 17.8 17.7 17.1 16.9 16.7 16.3 16.3 16.2 15.9 15.2 14.7 14.5 14.1 14.0 12.3 11.7

9.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

55.0

60.0

65.0

70.0

75.0

80.0

Percent obese among adults 20 years or older by Community areas, Hawaii BRFSS combined year data set, 2000-2003

(age-adjusted)