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Prevention and Treatment of Obesity: Lessons From the Schools to the Clinic

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Title: Prevention and Treatment of Obesity: Lessons From the Schools to the Clinic


1
Prevention and Treatment of Obesity Lessons From
the Schools to the Clinic
  • Gary D. Foster, Ph.D.
  • Center for Obesity Research and Education
  • Temple University

2
Prevalence 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
3
Consequences 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.
4
School-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

5
Planet 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)
6
Planet Health- Gortmaker et al. (1999)

Gortmaker et al. (1999) Arch Pediatr Adoles
Med.,153 (4)
7
Gortmaker et al. (1999) Arch Pediatr Adoles
Med.,153 (4)
8
CHOPPS- (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
10
A 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.

11
Specific 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

12
Study 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.

13
Sample Description at Baseline by Treatment Group
Intervention Control
14
Race/Ethnicity
15
Comparison of Weight Status Categories at Baseline
There were no significant differences in weight
status at baseline between control and
intervention groups
16
Intervention
  • The School Nutrition Policy Initiative included
    the following components
  • school self-assessment
  • nutrition education
  • nutrition policy
  • social marketing
  • parent outreach

thefoodtrust.org
17
The Intervention Halved the of New Cases of
Overweight Children.
Foster et al. Pediatrics, 2008
18
Corner 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

19
Healthy 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

20
HCSI
  • 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

21
HCSI 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

22
HCSI 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
23
HEALTHY
  • HEALTHY Study Group
  • Funded by
  • National Institute of Diabetes and Digestive and
    Kidney Diseases
  • National Institutes of Health

24
HEALTHY
  • 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

25
HEALTHY 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

26
HEALTHY Feasibility Study- Percent with BMI ?
85th Percentile by Ethnicity -
Kaufman et al., Diabetes Care, 2006
27
HEALTHY Feasibility Study- Distribution of BMI
Percentile Categories -
28
HEALTHY Feasibility Study- Results (Mean, SD) -
Kaufman et al., Diabetes Care, 2006
29
HEALTHY Feasibility Study- Results (Continued) -
Kaufman et al., Diabetes Care, 2006
30
HEALTHY Feasibility Study- Distribution of Risk
Indicators -
31
HEALTHY
- 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

32
Primary Prevention TrialIntegrated Intervention
Components
Communications
Physical Education
Food Service
Behavior
33
Primary 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

34
Primary 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

35
Primary 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

36
Primary 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

37
HEALTHY
- 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

38
HEALTHY
- Distribution of BMI Percentile
Categories -
The HEALTHY Study Group, Diabetes Care, 2009
39
HEALTHY
- Fasting Glucose at Health Screening-
The HEALTHY Study Group, Diabetes Care, 2009
40
Distribution 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
41
HEALTHY
- 6th Grade vs. 8th Grade -
42
A 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.
43
Obstructive 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)

44
Consequences of Obstructive Sleep Apnea
  • Hypertension
  • Congestive heart failure
  • Nocturnal arrhymthmias
  • Myocardial infarction
  • Pulmonary hypertension
  • Stroke
  • Impaired glucose tolerance / insulin resistance

45
Consequences of Obstructive Sleep Apnea
  • Cognitive impairment
  • Sexual dysfunction
  • Injury due to automobile accidents
  • Injury due to work-related accidents

46
Apnea 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

47
Apnea-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

48
Sleep AHEADSleep Apnea in Look AHEAD
Participants
49
Rationale
  • 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.

50
Sleep Ahead Participants (N305)

No difference between DSE and ILI groups
51
Sleep Ahead Participants (N305)
No difference between DSE and ILI groups
52
Sleep Disordered Breathing in Obese Patients with
Type 2 Diabetes (N305)
13.4 No OSA
22.6 Severe
33.5 Mild
30.5 Moderate
53
Undiagnosed, 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
54
306 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
55
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58
Conclusions
  • 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.

59
A 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

60
A 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

61
A Self-Regulation Program for the Maintenance of
Weight Loss- Wing et al., NEJM, 2006.
62
A 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
63
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