Familial And Environmental Determinants of Obesity in American Indian Children

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Familial And Environmental Determinants of
Obesity in American Indian Children

• Alexandra Adams, MD, PhD
• Population Health Sciences Seminar
• Nov 17, 2003

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Objectives

• Background on childhood obesity
• WINGS project
• Participatory research-definition and rationale
• WINGS results
• Conclusions

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The Childhood Obesity Epidemic

• 15 of children (6-19yrs) and 10 of preschool
  children (2-5yrs) are are currently overweight
• 5 in 1970 1980 and 11 in 1990
• Overweight is one of the top five reasons for
  health care visits among children and
  adolescents.
• Diabetes in kids up 10 X in 10 years
• 50-90 of all children diagnosed with type 2
  diabetes are obese

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Pediatric Obesity in Minority Populations

• Minority populations have higher prevalences of
  pediatric obesity
• 22 African-American Hispanic children are now
  overweight
• 27 of AA and Hispanic male children overweight
• Estimates for AI children range from 11 in
  pre-school children to 40 in 9-13 year olds

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Definition of Pediatric Obesity

• BMI (kg/m2) is the primary measure with standards
  based on the CDC growth charts of BMI for age,
  5/00.
• Normal BMI
• At risk for overweight 85th and
• Overweight 95th
• No cross cultural data are available to compare
  the validity of BMI
• BMI is 80 accurate in predicting body fat
• CDC web for growth charts www.cdc.gov/growthchart
  s

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Overweight children
Percentage of children above the 95th percentile
BMI (based on 1960s levels)
From CDC National Center for Health Statistics
NHES II, III NHANES I, II, III, and 99/00
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Increasing obesity in WIC children aged 2-5,
1994-2000
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High Birth Weights in Wisconsin Tribes
From Community Health Profile, GLITC Epi Center00
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The Fat Cycle A Model
Adams, 02
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Factors Contributing to Pediatric Obesity

• Decreased exercise
• Increased TV watching
• High fat/calorie diets
• Infant feeding practices

• Parental obesity
• Maternal gestational diabetes
• High birth weight
• Socioeconomic status
• Genetics
• Metabolic rate
• Insulin metabolism

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Walking and bicycling by children aged 5 15
dropped 40 between 1977 1995 U.S DOT 1997
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Childrens Television Resource Education Center

68 increase Video Games and Children. ERIC Digest

• is sedentary
• takes away time from other activities
• associated with eating

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Health Consequences of Pediatric Obesity

• Hyperlipidemia
• Early menarche
• Increased growth then stunting
• Abnormal glucose metabolism hyperinsulinemia
• Increased heart rate and cardiac output

• Fatty liver elevated transaminases
• Orthopedic problems
• Hypertension
• Sleep apnea
• Depression and poor self-image

• Over 50-80 of obese children become obese
  adults!

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• The Wisconsin Nutrition and Growth Study, a
  Participatory Research and Obesity Prevention
  Project with Three Wisconsin Tribes

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Participatory research

• Is a mutually respectful partnership between the
  researchers and the community being studied
• Includes participation in formation of research
  question, research design, data collection, data
  analysis, and dissemination of results
• Value placed on the knowledge generated from the
  experience, lives and self-concept of the people
  involved in the research
• Intended outcome is individual and community
  empowerment to define issues and take action
• A process that educates both the researchers and
  the research participants
• Tsark, 2001.

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Adams,02
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Process Summary

• Step 1 Determine mutual concerns and research
  priorities
• Step 2 Define problem and collect background
• Step 3 Do a pilot project
• Step 4 Return results and assess community
  response
• Step 5 Find funding and take action
• Step 6 Return results to community and
  collaborative interpretation of data

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Step 1 Mutual Concerns and Research Priorities

• Meetings with tribal leaders and community health
  workers
• Preliminary epidemiology from GLITC
• Tribal resolutions/priorities for primary
  prevention
• Already ongoing informal obesity/CVD risk
  surveillance in children

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Step 2 Define Problem Diabetes and CVD


From IHS Regional Differences in Indian Health
2000-2001
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Project Partners
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Funding Sources

• Great Lakes Native American Research Centers for
  Health (GLNARCH)-NIH
• National Heart, Lung and Blood Institute
• Wisconsin Dept. of Public Health
• Menominee, Bad River and Lac du Flambeau Health
  Centers

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WINGS Project Objectives

• Work in Partnership with Wisconsin tribes to
• Determine the prevalence rates and contributing
  risk factors for obesity, CVD, and diabetes in
  American Indian children
• Perform growth modeling of familial and
  environmental determinants of obesity
• Design community-based early intervention
  programs to prevent obesity and reduce future CVD
  and diabetes risk

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Influences on childhood obesity
Health Screenings Parent Surveys
WIC Charts
1
2
3
4
5
6
7
8
Gestation
Early Growth and Nutrition
Current Growth, Risk Factors, Nutrition Activity
Heredity
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Screenings

• Usually done over 2 or 3 days
• Kindergarten through 2nd graders (5 through 8
  y/o) invited through letter to parents
• Measures performed by trained university
  researchers and tribal health personnel
• Children receive t-shirt, stickers, pencils
• Schools/tribal health clinics provided
  compensation for participation

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Measures

• Anthropometrics
• Height Weight
• Hip waist circumference
• Tricep and subscapular skinfold thickness
• Blood pressure

• Parent survey
• 61 questions covering
• Demographics
• Child medical history
• Family health
• Childs eating habits
• Childs physical activity
• Suggestions

• Blood (non-fasting)
• Glucose
• Total cholesterol
• HDL

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Screenings to Date

• 547 5-8 yr olds with 459 parental surveys
• 219 2-5 yr olds with 49 parental surveys
• Over 2,000 WIC records reviewed
• Data base goal of 300-350 children with 5-8 yr
  screening, parental survey, and WIC or chart data

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BMI categories for WINGS children
NHANES 99/00
WINGS Children
N695, unweighted
n362
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BMI categories for girls compared to boys in WINGS
Girls175
Boys187
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Body fat and BMI category
p 35
WaistHip ratio and BMI category
WaistHip ratios varied from .72 to 1.20.
p 36
Blood pressure and BMI category
Blood pressure cutoffs based on values published
by National High Blood Pressure Working Group of
NHLBI (1996).
p 37
Glucose and BMI category
Very few (risk (140 mg/dl) glucose levels
p 38
Cholesterol and BMI category
TC p 0.107 HDL p 39
Mothers BMI is related to childs BMI
N246p 40
Relationship of BMI category to CVD risk factors
1.5
19
15
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22
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Risk Factors BP95th WH ratio.90 TC 170
mg/dl HDL Childs BMI
p 41
Parental BMI self-report by survey
76 of mothers and 78 of fathers are overweight
or obese
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Are you concerned about your childs risk of
future heart disease?
10.7
51.2
29.5
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Are you concerned about your childs risk of
future diabetes?
15.2
38.9
41.8
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Are you concerned that your child might be at
risk for overweight?
5.3
5.3
54.1
26.6
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Parental Attitudes

• Only 21 of parents whose child was overweight
  were aware of their childs weight status
• Only 15 and 11 of all parents were a lot
  concerned about future risk of diabetes and CVD
• No differences were found between parental
  concern for future diabetes or CVD risk between
  parents who thought their child was overweight
  vs. all other parents
• Many excellent suggestions were provided by
  parents

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Early Predictors of Child Adiposity at Ages 5-8
p 47
Lifestyle Predictors of Child Adiposity at Ages
5-8
pBadstuff candy pop sweetened juice TV
meals with TV Active after school outdoor play
weekend outdoor play Goodstuff vegetables
fruit juice milk (suppressor)
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Predictors of Childhood BMI 95

• Birth Weight 4,000grams
• OR 3.2 , p
• Maternal Weight Category (BMI30)
• OR 2.1, p
• Gestational Diabetes (regardless of maternal wt)
• OR 2.4, p

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Breastfeeding and Obesity

• Recent evidence suggests breastfeeding may be
  protective of obesity
• A study in S. Germany of 9,200 5-6 year-olds
  found a 62 difference in the prevalence of
  obesity in breastfed vs. non-breastfed infants
  (von Kries et al 1999)
• A National study indicated infants breastfed for
  6 months had a 22 reduction in prevalence of
  overweight compared to formula fed children
  (Gillman et al 2001)
• 2 localized studies in the U.S. found reductions
  in obesity of 20 or greater

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WIC Data Analysis

• Data was collected from charts 3 tribal WIC
  sites-Menominee, Lac du Flambeau, and Bad River
  on all children born Jan 1, 1995-present
• 1727 child and 1118 maternal charts reviewed
  leading to 515 maternal and 680 child charts with
  breastfeeding, birthweight and pre-pregancy
  weight information
• Data was entered into a secure database and
  analyzed using SPSS for analysis of variance and
  chi-square determination

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Breastfeeding Duration

• 72.3 of mothers initiated breastfeeding, only
  29 of this group (21 of total pop.) breastfed
  for 6 months or longer

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Mean BMI of Children as a Function of
Breastfeeding
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Maternal Pre-Pregnancy weight and child
birthweight

• Mothers
• Obese 29
• Overweight 24
• Normal weight 47

• Children
• LGA 20
• SGA 4
• Normal weight 76

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Childrens BMI is a Function of Maternal PPW
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Maternal PPW, Breastfeeding and Mean BMI of
Children

No significant difference appears between Bfed
and non-BFed when maternal PPW is controlled
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Relationship of Birth Weight and Future BMI

• All points have p

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The Relationship of Birth Weight, BMI
Breastfeeding

• P values show significance at only the 12 month
  age point

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Factors that have not shown an impact on BMI in
WINGS children ages 5 - 7

• Breastfeeding
• Parental education level
• TV watching
• Soda pop consumption
• Milk consumption
• Physical activity on weekends
• Fruit and vegetable consumption

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Conclusions

• Maternal PPW and birth weight are significant
  factors influencing BMI of children at nearly all
  time points up to age 5
• Breastfeeding shows a slight reduction in BMI
  when these factors are not controlled
• When PPW and birth weight are controlled this
  relationship virtually disappears this may be
  due to
• Reduced N at each data point-previous studies had
  more participants
• Breastfeeding has only a very small effect in
  relation to other factors

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Conclusions

• Early overweight is a significant problem in
  Wisconsin American Indian children
• Significant predictors of child overweight were
  maternal BMI, gestational diabetes, birth weight
  and combined lifestyle factors
• Parents are more concerned about diabetes and
  heart disease than overweight
• Research results are being shared with the
  community to aid in the design of appropriate
  interventions

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Accomplishments

• Increased community awareness of childhood
  obesity and its link to future diabetes and CVD
• Increased emphasis on prevention for children
• Mobilization of community resources and
  partnering with outside sources to create
  nutrition and physical activity teams
• Increased comfort with research process
• Obtaining NIH-NARCH funding
• Creation of first MOU between UW and tribes
• Empowerment of tribes to accept or decline
  research in their communities

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WINGS Project Timeline
Continuing data collection Obtain intervention
funding Begin intervention
Preliminary Screenings Funding Proposals Gathering
participants
Continuing data collection Growth curve
modeling Community assessment
Returning data to the community
2001
2002
2003
2004
2005
2006
Collaborative interpretation of summary
data Continuing data collection Intervention
development
Continuing data collection Ongoing
intervention Intervention assessment
WIC data Continuing screenings GLNARCH Planning
meeting
We are here
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Community and University Researchers

• University of Wisconsin
• Alex Adams MD, PhD
• Heather
• Ron Prince, MS
• Menominee
• Mark Caskey, RN
• Patty Burr, RN, CDE
• Scott Kruger, RD
• Tracy Prey
• Jerry Wacau

• Bad River
• Mark LeCapitaine, RD
• Becky Lemieux
• Sue Houle
• Mary Big Boy
• Lac du Flambeau
• Anita Dionne
• Sue Williams, RN
• Glenda Valliere, RN
• Donna Clark, RN
• Robin Carufel

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Thanks to all the kids and parents that
participated !