Sarah Armstrong, MD Director, Healthy Lifestyles Program North Carolina School Community Health...

Sarah Armstrong, MDDirector, Healthy Lifestyles Program

North Carolina School Community Health Alliance Conference

December 14, 2009

The Childhood Obesity The Childhood Obesity Epidemic:Epidemic:How we got here, what it means for a child’s health, and How we got here, what it means for a child’s health, and what you can dowhat you can do

All Rights Reserved, Duke Medicine 2007

Name that FoodENRICHED FLOUR (WHEAT FLOUR, NIACINAMIDE, REDUCED IRON, THIAMIN MONONITRATE [VITAMIN B1], RIBOFLAVIN [VITAMIN B2], FOLIC ACID), CORN SYRUP, HIGH FRUCTOSE CORN SYRUP, DEXTROSE, VEGETABLE OIL (SOYBEAN, COTTONSEED AND HYDROGENATED COTTONSEED OIL† WITH TBHQ AND CITRIC ACID FOR FRESHNESS), SUGAR, CRACKER MEAL, CONTAINS TWO PERCENT OR LESS OF WHEAT STARCH, SALT, DRIED STRAWBERRIES, DRIED APPLES, DRIED PEARS, CORNSTARCH, LEAVENING (BAKING SODA, SODIUM ACID PYROPHOSPHATE, MONOCALCIUM PHOSPHATE), CITRIC ACID, MILLED CORN, MODIFIED WHEAT STARCH, GELATIN, CARAMEL COLOR, PARTIALLY HYDROGENATED SOYBEAN AND/OR COTTONSEED OIL†, MODIFIED CORN STARCH, XANTHAN GUM, SOY LECITHIN, COLOR ADDED, NIACINAMIDE, REDUCED IRON, RED #40, VITAMIN A PALMITATE, YELLOW #6, PYRIDOXINE HYDROCHLORIDE (VITAMIN B6), RIBOFLAVIN (VITAMIN B2), THIAMIN HYDROCHLORIDE (VITAMIN B1), FOLIC ACID, TURMERIC COLOR, BLUE #1.†LESS THAN 0.5g TRANS FAT PER SERVING


600 calories per package (2 pop tarts)

38 grams of sugar

“No” trans fat

POP TARTS


Obesity Trends Worldwide


South East Asia & Pacific RegionNauru 78%Tonga 70%Samoa 63%Niue 46%French Polynesia 44%

AfricaSeychelles 28%South Africa 28%Ghana 20% Mauritania 19%Cameroon (urban) 14%

South Central AmericaPanama 36%Paraguay 36%Peru (urban) 23%Chile (urban) 23%Dominican Republic 18%

North AmericaUSA 33%Barbados 31%Mexico 29%St Lucia 28%Bahamas 28%

Eastern MediterraneanJordan 60%Qatar 45%Saudi Arabia 44%Palestine 43%Lebanon 38%

European RegionAlbania 36%Malta 35%Turkey 29%Slovakia 28%Czech Republic 26%

% Obese

0-9.9%

10-14.9%

15-19.9%

20-24.9%

25-29.9%

≥30%

Self Reported data


Obesity Trends* Among U.S. AdultsBRFSS, 1985

No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


Obesity Trends* Among U.S. AdultsBRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2008

2008

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


Turning the corner on childhood obesity…


03-04 N=2,15903-04 N=981

0

5

10

15

20

25

1963-651966-70

1971-741976-80

1988-9499-00

01-0203-04

US 6-11 yr

US 12-19 yr

NHANES data sources: Ogden et al. Prevalence and Trends in Overweight Among US Children and Adolescents, 1999-2000. JAMA 2002;288(14):1728-1732. Ogden et al. Prevalence of Overweight and Obesity in the United States, 1999-2004. JAMA 2006;295(13):1549-1555.

19.019.520.020.521.021.522.0

2004 2005 2006 2007

AR grades K-6AR grades 7-12

The Arkansas “Experiment:” Act 1220 (2006)


ADULT BMI

• Weight (kg) / Height (cm) squared

• Between 18 and 25 is normal

• Between 25 and 30 is “overweight”

• Above 30 is “obese”

http://heartline.in/images/diabetes_BMI_chart.gif


Pediatric BMI

-same calculation

-read as percentile

-BMI correlates with risk for disease

-shift paradigm from weight loss to weight maintenance


For example, a five year old girl with BMI of 20kg/m2 who maintains her weight but increases her height normally will get into the “green zone” by age 8.

The same girl, if she gains weight slowly, and continues to gain height, will get into the “green zone” by age 10.


Source: Mokdad et al., Diabetes Care 2000;23:1278-83; J Am Med Assoc 2001;286:10.

Diabetes Trends* Among Adults in the U.S

1990 1995

2001


“Pre-Diabetes” or “Insulin Resistance Syndrome”


Polycystic Ovarian Syndrome“PCOS”


Childhood Hypertension


Children and Cholesterol


Fatty Liver Disease

“Non-alcoholic steatohepatitis”


Osteoarthritis

Percent of total daily calories from soda, juice, and milk

0

2

4

6

8

10

12

14

1977 2001

SodaJuiceSoda + JuiceMilk

Neilsen SJ, Popkin BM. Changes in beerage intake between 1977 and 2001. American Journal of Preventive Medicine. 2004; 27(3):205-210.


Blount’s Disease“Pathologic tibia varum”


Childhood depression

• Quality of life for obese children lower than that for children with cancer

• Bullying, teasing, social isolation and inability to participate in active or social events may contribute

• Rates of depression and anxiety are 2-3 times higher in obese adolescents than in normal weight teens.

Reference: Barlow et al, Pediatrics (s): 2007


Economic Update

• Direct medical costs: >9% of all US health expenditures

• Estimated direct and indirect costs: $117 billion in 2000 now estimated at $130 billion per year

• Expenditures expected to increase as obese children become obese adults with chronic illnesses


PREVENTION, ASSESSMENT AND TREATMENT MESSAGE

• 5 fresh fruits/veggies a day• 3 structured family meals • 2 hours or less of screen time• 1 hour of physical activity a day• “Almost none” sugar-sweetened beverages


5 Fruits & VegetablesGoal 5 or more servings/day (1/2 cup = 1 serving) USDA recommends 9 servings/day.

Why eat fruits and vegetables? • Low in calories• High in fiber (fiber goal: age + 5)• Improve satiety• Rich in vitamins and minerals• Natural toothbrushes

Model of Eating Competence:1. No clean plate club rules2. Parent feeding responsibility3. Child feeding responsibility Ellyn Satter, Child of Mine


3 Structured Meals

Family guidance: • Eat at the table, at home, with the TV off.• Offer a variety of foods-protein, grain, vegetable, fruit, and reduced

fat milk or water – but no short order cooking!• Create positive meal atmosphere

Skipping breakfast is strongly associatedwith obesity. Eating breakfast is protectiveagainst developing obesity.• Fruit and string cheese• Granola bar and yogurt• Cheese and crackers• Peanut butter toast• Cereal (<9g sugar) and milk• Instant breakfast drink

Barlow et al, Pediatrics, 2007


Creative Labeling

Children Under 8 cannot distinguish commercials from reality

No regulation on health claims on box, only Nutrition Label is regulated

“fortified with 8 essential vitamins and iron”


Disney and Obesity


“Healthy Plate”American Diabetes Association

American Cancer Institute


0% 20% 40% 60% 80% 100%

2 Hours or less of TV/media timePercent of 8-18 year-olds with each mediumPercent of 8-18 year-olds with each medium in their bedroomin their bedroom::

TelevisionTelevision

Internet accessInternet access

VCR/DVD playerVCR/DVD player

Video game consoleVideo game console

68%68%

20%20%

49%49%

Cable/satellite TVCable/satellite TV

ComputerComputer

37%37%

31%31%

20%20%

54%54%

Premium cable channelsPremium cable channels

Source: Kaiser Family Foundation, Generation M: Media in the Lives of 8-18 Year-Olds, March 2005: kff.org


TV Rules: Parent’s Role Percent of all 8-18 year-olds who say they have:

TV rules that TV rules that are enforced are enforced

“most” of time“most” of time

26%26%53%53%

20%20%

TV rules that TV rules that are are enforcedenforced some, a little some, a little

or neveror never

No rulesNo rulesabout TVabout TV



Household Media Environment Percent of 8-18 year-olds living in homes where:

TV is “usually” TV is “usually” on during on during

mealsmeals

63%63%

36%36%

TV not usually TV not usually left on during left on during

mealsmeals



1: Or more hour of active time

At least one hour of outdoor time per day associated with decreased rates of obesity and chronic illness

National survey data indicate that 20% of US children 8 to 16 years of age reported 2 or fewer bouts of vigorous physical activity per week

Decreased school activity time as compared with 10 years ago.

Perceived neighborhood safety important determinant in child’s outdoor play time.

Built environment and access to safe play a critical concern.

Anderson et al. Relationship of physical activity and television watching with body weight and level of fatness among children: results from the Third National Health andNutrition Examination Survey. JAMA. 1998;279:938–942


Almost none: Sweetened Beverages

Liquid calories:12 oz. soda= 150 calories 10 tsp sugar12 oz. Kool Aid= 150 calories 10 tsp sugar

• Generally non-nutritive • Replaces source of calcium- needs 500-1300 mg/day

- Peak calcium needs in adolescence for bone density- Vitamin D

• Interferes with appetite for other healthful foods, especially in young children.

• Caffeine content-stimulant, restlessness, interferes with sleep


Fruit drinks/fruit punch

• Calories per 12 oz serving?– 171

• Teaspoons of sugar?– 15

Overall 60% increase in the risk of becoming

obese with each additional can of sugar

sweetened drink consumed


What about 100% fruit juice?

Recommendations

1. None for children under 1

2. Ages 1-7, 4-6 ounces/day

3. Ages 7 and up, no more than 12 ounces/day


Acceptance and Behavioral Control as Determinants of Parenting Style

Parenting Style

High Acceptance Low Acceptance

High Control Authoritative Authoritarian

Low Control Indulgent Disengaged

Adapted from Chassin et al, J Pediatric Psychology 2005


Age-Appropriate Family Focus

Breastfeeding

Rules and structure“Feeding responsibility”

Rules and structureRole modeling

Role modelingSupport of teenEncouraging good peer

influenceEllyn Satter, Child of Mine


CLINICAL CARE The Healthy Lifestyles Program

RESEARCH

EDUCATION

ADVOCACY

HEALTHY LIFESTYLES


Risk Reduction:BMI Stabilization

1015

2025

3035

-12 -6 0 6

Time, months

Healthy Lifestyles

BM

I, kg

/m2

N=10; random cohort sample


Risk Reduction: BMI in Cohort

0

5

10

15

20

25

30

35

OW Obese SevereObesity

BaselinePost-HLP

Nu

mb

er

of

Pati

en

ts


Body Fat Percent

30

32

34

36

38

40

42

44

BF%

BaselinePost-HLP

Perc

en

til

e


Initial Cohort Results

Variable* Initial Last

Weight (kg) 74.9 76.2

BMI 32.5 32.2

Z-score 5.2 5.1

Co-Morbidities 3.8 2.4

* Mean Values

Mean time from initial to last visit was 7.4 months


Changes in Blood Pressure:Cohort Patients

Blood Pressure Initial Visit Last Visit

Normal 11 20

Pre-hypertension 5 5

Stage 1 Hypertension 8 7

Stage 2 Hypertension 10 2

Total 34 34


Pediatric and Adolescent Lifestyle Survey Results:Cohort Patients

0

5

10

15

20

25

30

35

PALS Score

StartPost-HLP


Mood and Feeling Questionnaire: Cohort Patients

• Score of 10 or greater indicates depression.

• 8 patients had an initial score of 10 or greater– 6 (75%) of these

patients score returned to normal

– No patient with an initial score <10 had a score of > 10 at last visit

0

1

2

3

4

5

6

7

MFQ Score

StartPost-HLP


• http://www.eatsmartmovemorenc.com/• http://pediatrics.duke.edu/modules/

ctr_ped_cendo_svc/index.php?id=1• http://kidshealth.org/• http://www.bam.gov/• http://win.niddk.nih.gov/publications/child.htm

Resources

Thank you

Sarah Armstrong

Director, Healthy Lifestyles

Duke Children’s Primary Care

December 14, 2009

Sarah Armstrong, MD Director, Healthy Lifestyles Program North Carolina School Community Health...

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