Title: Prevention and Treatment of Obesity: Lessons From the Schools to the Clinic
1Prevention and Treatment of Obesity Lessons From
the Schools to the Clinic
- Gary D. Foster, Ph.D.
- Center for Obesity Research and Education
- Temple University
2Prevalence of Obesity
in Children Adolescents
Percent
1971-74
1976-80
1988-94
2003-06
2001-02
1999-00
Ogden et al., JAMA, 2008
Source Centers for Disease Control and
Prevention, http//www.cdc.gov
3Consequences of Childhood Obesity
- Current consequences
- Medical
- Increased prevalence of adult conditions
- Hypertension
- Increased cholesterol
- Type II Diabetes
- Psychosocial
- Peer rejection
- Bullying
- Academic performance
- Obese kids become obese adults
- Among equally obese adults those overweight as
children have greater prevalence of medical
conditions.
Must A. Anderson S. Nutr. Clin. Care, 2003.,
Baker S et al., Journal of Ped. Gastro. Nutr.
2005., Wearing et al, Obesity Reviews, 2006.
4School-Based Prevention Approaches
- Schools provide ideal settings for primary and
secondary prevention intervention initiatives for
the following reasons - Access to large numbers of children
- Costs to families are minimal
- Integration into current curriculum
- Opportunities to practice healthy lifestyle
behaviors - Environments where healthy lifestyles are modeled
by teachers, staff and peers
5Planet Health- Gortmaker et al. (1999)
- Subjects 6th-8th graders (5 intervention
schools, 5 control schools) - Intervention improving activity and dietary
behaviors via classroom and PE lessons. - Emphasis on decreased
- television viewing
- high-fat food intake
- Emphasis on increased
- moderate-vigorous physical activity
- fruit vegetable intake
- Timeline2 years
Gortmaker et al. (1999) Arch Pediatr Adoles
Med.,153 (4)
6Planet Health- Gortmaker et al. (1999)
Gortmaker et al. (1999) Arch Pediatr Adoles
Med.,153 (4)
7Gortmaker et al. (1999) Arch Pediatr Adoles
Med.,153 (4)
8CHOPPS- (James 2004)
- Subjects 644 children (7-11 yrs old) in 6
English primary schools - Intervention Nutrition education,
- Discouraged consumption of fizzy drinks.
- Encouraged water consumption.
- Timeline1 year.
James et al. (2004) BMJ 328
9- Overweight obesity prevalence increased 7.5
in control and decreased 0.2 in intervention. - No significant difference for BMI or z score.
- Intervention reduced intake of carbonated
beverages at 1 year (p0.02) - Both control and intervention groups
significantly increased their water intake
(p0.003, 0.02
respectively) at 1 year.
James et al. (2004) BMJ 328
10A Randomized Trial of a
School-Based Obesity Prevention Program
- Gary Foster1, Sandy Sherman2,
- Kelley Borradaile1, Karen Grundy3, Stephanie
Vander Veur1, Joan Nachmani4, Allison Karpyn2,
Shiriki Kumanyika5, Justine Shults5 - 1 Temple University
- 2 The Food Trust
- 3 Bryn Mawr College
- 4School District of Philadelphia
- 5University of Pennsylvania
- Pediatrics, 2008.
11Specific Aims
- To assess the effects of a school-based
prevention program on the incidence, prevalence
and remission of at risk ( 85th percentile BMI)
and overweight ( 95th percentile BMI) between
intervention and control schools over a 2-year
period. - To assess the effects of a school-based
prevention program on dietary intake, physical
activity, and body image over a 2-year period
12Study Design
- RCT clustered design with repeated measures at
baseline, year 1, year 2. - 35 K-8 schools with 50 of students eligible
for free or reduced price meals were sorted into
5 clusters to control for enrollment size and
food service type. - 2 schools were randomly selected from each
cluster. - 1 school within each cluster was randomly
assigned to either treatment or control condition.
13Sample Description at Baseline by Treatment Group
Intervention Control
14Race/Ethnicity
15Comparison of Weight Status Categories at Baseline
There were no significant differences in weight
status at baseline between control and
intervention groups
16Intervention
- The School Nutrition Policy Initiative included
the following components - school self-assessment
- nutrition education
- nutrition policy
- social marketing
- parent outreach
thefoodtrust.org
17The Intervention Halved the of New Cases of
Overweight Children.
Foster et al. Pediatrics, 2008
18Corner Stores
- Part of the urban landscape and have the
potential to undermine school-based efforts - Often located a few hundred feet from schools
- Understudied area
19Healthy Corner Store Initiative (HCSI)
- Multi-component school based interventions can be
effective at curbing the development of
overweight - Still observed 7 incidence of new cases of
overweight in the intervention schools - Still room for improvement
- HCSI targets environments beyond the school
20HCSI
- Community-based, multi-faceted, and broad-based
intervention administered by The Food Trust - 2 year study
- 2 Goals
- Decrease the purchase of high calorie snacks and
beverages - Increase the percentage of healthy snacks and
beverages available at stores
21HCSI Research Design
- 10 Philadelphia K-8 schools and proximal corner
stores randomly assigned to HCSI or control
conditions - Students in grades 4 through 6 (over 50 of
students qualifying for free and reduced meals) - Measures (data collected annually)
- Student purchases
- Questionnaire assessing shopping trends
- BMI z-scores
- Corner store inventory
22HCSI Baseline Results
N817 Purchases Variable Mean SD Total
amount spent () 1.08 0.93 Total number of
items 2.1 1.4 Food Items 1.6
1.2 Beverage Items 0.5 0.6 Calories (kcal)
360.0 288.1 Calories from Fat
() 29.0 22.5 Calories from Protein () 4.8
5.5 Calories from Carbohydrates () 65.7
29.5 Dietary Fiber (g) 1.5 1.7 Sodium
(mg) 538.9 776.8
23HEALTHY
- HEALTHY Study Group
- Funded by
- National Institute of Diabetes and Digestive and
Kidney Diseases - National Institutes of Health
24HEALTHY
- Epidemic increase rates of obesity type 2
diabetes (T2D) in children and youth - Environmental risk factors
- Diet quality physical activity sedentary
behavior - The NIDDK funded a primary prevention trial
- 4 semester intervention in 6th -8th grade
- Preceded by a series of pilot studies
- Conducted at 7 field centers
25HEALTHY Feasibility Study- Study Sample -
- 1740 participants in 12 middle schools
- 145 ? 34 students per school (range 85-199)
- Age 13.6 ? 0.6 years (range 12-16)
- Sex 43 male, 57 female
- Ethnicity
- 53 Hispanic
- 23 African American
- 15 Caucasian
- 2 American Indian
- 6 Other
- Representative sample
26HEALTHY Feasibility Study- Percent with BMI ?
85th Percentile by Ethnicity -
Kaufman et al., Diabetes Care, 2006
27HEALTHY Feasibility Study- Distribution of BMI
Percentile Categories -
28HEALTHY Feasibility Study- Results (Mean, SD) -
Kaufman et al., Diabetes Care, 2006
29HEALTHY Feasibility Study- Results (Continued) -
Kaufman et al., Diabetes Care, 2006
30HEALTHY Feasibility Study- Distribution of Risk
Indicators -
31HEALTHY
- Main Trial Design -
- 42 middle schools 6 in Philadelphia
randomized to intervention or control - Intervention
- Environmental changes to school food service and
physical education class activities - Communications and promotional campaign
- Behavior change activities, messages, and goal
setting - Intervention goal ? risk factors for T2D
- 3 primary outcomes indicating risk
- BMI 85th percentile
- Fasting glucose 100 mg/dL
- Fasting insulin 30 µU/mL
32Primary Prevention TrialIntegrated Intervention
Components
Communications
Physical Education
Food Service
Behavior
33Primary Prevention TrialPhysical Education
- Increasing MVPA levels in PE classes
- PE lesson plans in units or themes
- Core units basketball, fitness, soccer, team
handball, FLOW - Additional units cooperative games, dance,
frisbee, football, lacrosse, softball, street
hockey, track field, racquet sports, volleyball - Training programs focusing on
- Class management
- Reducing inactivity
- Motivational techniques to maximize PE teacher
willingness to participate in intervention
34Primary Prevention TrialNutrition
- Lower the average fat content of all items served
in order to decrease student dietary fat intake
to lt 35 of total calories from fat - Increased fruit and vegetables served to 3
servings per student each day in order to
increase student total daily intake to 5 servings - Serve dessert snack foods with lt 200 calories per
single serving size package in order to reduce
student energy intake from these foods - Eliminate all added sugar beverages served except
for flavored milk lt 1 fat in order to reduce
student energy intake from these sources lt 6 oz
of 100 fruit juice can be served only as part of
NSBP - Increase whole grain foods served with gt 2 g
fiber per serving in order to increase student
intake from these sources
35Primary Prevention TrialBehavior
- FLASH (Fun Learning Activities for Student
Health) - Brief classroom activities designed to increase
knowledge, enhance decision making skills,
enhance social influence, and promote peer
involvement/interaction - More/Less Campaign
- Individual and group behavior change initiatives
aimed at enhancing self-awareness, self-efficacy,
and skill in performing healthier behaviors - Family Outreach
- Involve parents/guardians/family by providing
information, strategies, and planned
opportunities to support youth in accomplishing
behavior goals
36Primary Prevention TrialCommunications
- School-wide campaigns to support and extend
- PE and food service environmental interventions
- Behavior intervention components
- Recruitment and retention
- Engage school staff
- Project identity and branding
- Student Generated Media
- Reflect themes of choice, strength, and balance
37HEALTHY
- Consented 6th Grade Students -
- Total Consented 6,554 (59)
- Total Screened 6,415 (58)
- Total in Cohort 6,367
- Family History of Diabetes 3,885 (63.9)
- Race/Ethnicity
- 53 Hispanic
- 20 African American
- 19 Caucasian
- 5 Mixed Race
- 2 Asian
- 1 Other
38HEALTHY
- Distribution of BMI Percentile
Categories -
The HEALTHY Study Group, Diabetes Care, 2009
39HEALTHY
- Fasting Glucose at Health Screening-
The HEALTHY Study Group, Diabetes Care, 2009
40Distribution of BMI Percentile Categories
HEALTHY Feasibility Study (8th grade cohort)
HEALTHY Study (6th grade cohort)
The HEALTHY Study Group, Diabetes Care, 2006 The
HEALTHY Study Group, Diabetes Care, 2009
41HEALTHY
- 6th Grade vs. 8th Grade -
42A Public Health Framework to Prevent and Control
Overweight and Obesity
- Food and Beverage Industry
- Agriculture
- Education
- Media
- Government
- Public Health Systems
- Healthcare Industry
- Business and Workers
- Land Use and Transportation
- Leisure and Recreation
- Community- and Faith-based Organizations
- Foundations and Other Funders
Social Norms and Values
- Home and Family
- School
- Community
- Work Site
- Healthcare
Sectors of Influence
Behavioral Settings
- Genetics
- Psychosocial
- Other Personal Factors
Individual Factors
Food and Beverage Intake
Physical Activity
Energy Expenditure
Energy Intake
Energy Balance
Adapted from Institute of Medicine, 2005.
43Obstructive Sleep Apnea Syndrome
- Obstructive sleep apnea a major public health
problem affecting 2-4 middle-aged population - Young et al. N Engl J Med 3281230-1235, 1993
- Recurrent apneic episodes secondary to upper
airway occlusion in presence of respiratory
effort (chest wall and abdominal wall movement)
44Consequences of Obstructive Sleep Apnea
- Hypertension
- Congestive heart failure
- Nocturnal arrhymthmias
- Myocardial infarction
- Pulmonary hypertension
- Stroke
- Impaired glucose tolerance / insulin resistance
45Consequences of Obstructive Sleep Apnea
- Cognitive impairment
- Sexual dysfunction
- Injury due to automobile accidents
- Injury due to work-related accidents
46Apnea Definitions
- Apnea cessation of breathing for gt 10 sec
- Hypopnea 50 decrement in airflow associated
with a 4 drop in oxygen saturation and/or an
arousal - Apnea-Hypopnea Index (AHI) number of apneas plus
hypopneas/hour of sleep
47Apnea-Hypopnea Index (AHI)
- AHI 0 - 5/hour Normal
- AHI 5 14.9/hour Mild OSA
- AHI 15 29.9/hour Moderate OSA
- AHI gt 30/hour Severe OSA
48Sleep AHEADSleep Apnea in Look AHEAD
Participants
49Rationale
- Weight loss is frequently recommended for obese
patients with obstructive sleep apnea (OSA), but
the empirical foundation for this recommendation
is not well substantiated. - Weight loss in sleep apneics improves but does
not eliminate sleep-disordered breathing and the
degree of improvement is not correlated with
weight loss.
50Sleep Ahead Participants (N305)
No difference between DSE and ILI groups
51Sleep Ahead Participants (N305)
No difference between DSE and ILI groups
52Sleep Disordered Breathing in Obese Patients with
Type 2 Diabetes (N305)
13.4 No OSA
22.6 Severe
33.5 Mild
30.5 Moderate
53Undiagnosed, Unscreened Sleep Disordered
Breathing in Obese Patients with Type 2 Diabetes
(N202)
12.4 No OSA
22.3 Severe
32.2 Mild
33.1 Moderate
54306 Assessed by Polysomnography
42 Excluded Not meeting inclusion criteria
(No OSA at baseline)
264
139 Assigned to receive DSE 139 Received
intervention as assigned
125 Assigned to receive ILI 125 Received
intervention as assigned
23 Lost to follow-up Did not come to
scheduled visit 0 Discontinued intervention
22 Lost to follow-up Did not come to
scheduled visit 0 Discontinued intervention
116 Included in analysis 0 Excluded
103 Included in analysis 0 Excluded
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57 58Conclusions
- OSA is highly prevalent among obese patients with
type 2 diabetes. - Weight loss has significant clinical benefits on
OSA among obese patients with type 2 diabetes. - Future studies are needed among younger patients
with less severe OSA and without type 2 diabetes.
59A Self-Regulation Program for the Maintenance of
Weight Loss- Wing et al., NEJM, 2006.
- Sample description
- N314
- lost at least 10 of their body weight in the
past 2 years - 81.2 female
- age 51.3 10.1 yrs
- BMI 28.6 4.8 kg/m2
- Study timeline 18 months
60A Self-Regulation Program for the Maintenance of
Weight Loss- Wing et al., NEJM, 2006.
- Randomly assigned to 3 conditions
- control (receiving newsletters, n105)
- face to face (n105)
- internet intervention (n104)
- Intervention groups emphasized daily weighing and
self-regulation - Contact with study groups and program content
delivered were the same in both intervention
groups
61A Self-Regulation Program for the Maintenance of
Weight Loss- Wing et al., NEJM, 2006.
62A Self-Regulation Program for the Maintenance of
Weight Loss- Wing et al., NEJM, 2006.
6 Months significant differences between face to
face group and control group 12 Months no
significant difference between groups 18 Months
control group differed significantly from face to
face group and internet group
Plt0.001
P0.003
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