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Childhood Obesity and the Modern Lifestyle: Implications for Future Generations

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Title: Childhood Obesity and the Modern Lifestyle: Implications for Future Generations


1
Childhood Obesity and the Modern Lifestyle
Implications for Future Generations
  • S. Kalani Brady, MD, MPH, FACP
  • Department of Native Hawaiian Health
  • UH John A. Burns School of Medicine
  • 6 July 2005

2
I think were 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 Childrens Hospital Los
Angeles www.discoveryhealthCME.com
3
Definition of Obesity
  • A chronic preventable disease
  • Obesity is defined as excess body fat (not simply
    excess weight)

4
Definition 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

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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 EDUCATION
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Percentage of Overweight Children and Youth who
Become Obese Adults
Preventive Medicine 1993 Vol. 22pp.
167-177 Arch Pediatr Adolesc Med Vol. 158 May
2004 pp. 449-452
S Gee, Kaiser Permanente
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Obesity Associated Morbidity in Childhood
  • Hypertension (9X risk compared to non-obese)
  • Dyslipidemia
  • Gall bladder disease
  • Polycystic ovarian syndrome
  • Fatty liver
  • Early menarche

Pediatrics 1998 102(3)
17
Obesity Associated Morbidity 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
  • Orthoslipped capital femoral epiphysis, Blounts
    disease, osteoarthritis of the knees, weight
    stress on growth plates of lower extremities
    (pain decreased ROM)

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Metabolic Syndrome among Overweight Children and
Adolescents
  • Metabolic Syndrome (1)
  • Criteria TG110 mg/dL, HDL-CCirc. 90, FBS110 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
20
Epidemiology of Overweight in Kids in General
U.S. Population
21
Preliminary data collected between 2000-2004
from the Nutrition Education Needs Assessment
Survey (NENAS) conducted in the public schools
every ten years shows an overweight problem
among youth and teenagers
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  • 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).

23
Ethnic Variation in Prevalence of Overweight
Among WIC Children
  • Multivariate analysis showed that ethnicity
    had a strong independent association with BMI and
    overweight.

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  • 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.

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  • 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 atrisk and overweight

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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.
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Why is childhood obesity 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

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Supersizing
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Increased Calories
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Less Physical Activity for Kids
MVPA 20 min in PE class 1991- 34.2 1997-
21.7
Activities that caused sweating and hard
breathing for at least 20 minutes on 3 or more of
the 7 days preceding the survey.
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TV 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

38
Childhood Overweight Family Risk Factors
  • One obese parent (3X increase)
  • Two obese parents (13X increase)
  • Early puberty

Pediatric Overweight A Review of the
Literature The Center for Weight and Health
College of Natural Resources University of
California, Berkeley http//www.cnr.berkeley.edu/c
wh/PDFs/Full_COPI_secure.pdf

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Overeating and Psychological Distress
  • Youths who overeat may have or be at risk for
    serious psychological distress, including
    deficits to self-esteem, compromised mood, and
    suicide risk. Overeating may be a tangible
    behavior that signals the need for intervention.
  • Ackard et al, Pediatrics 200311167-74

40
Depression and Obesity
  • Depressed adolescents are at increased risk for
    the development and persistence of obesity during
    adolescence.
  • Goodman and Whitaker, Pediatrics 2002109497-504
  • Depression during childhood is positively
    associated with BMI during adulthood.
  • Pine et al, Pediatrics 20011071049-56

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Lower Childhood SES and Insulin Resistance
  • Adverse social circumstances in childhood, as
    well as adulthood, are strongly and independently
    associated with increased risk of insulin
    resistance and other metabolic risk factors.
  • Lawlor et al, BMJ 2002325805

42
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 1998211746
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  • 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.

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  • Who needs medical intervention?

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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/e
29
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Treatment 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 ones weight (i.e.
    weight maintenance)

50
Treatment Principles
  • Health promotion is the primary goal (NOT
    dieting)
  • Family, not the child or teen, is identified as
    the patient

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Recommended Weight Goals
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/e
29
52
Summary Points for Management of Childhood
Overweight
  • 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 2004114217223

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Prevention of Pediatric Overweight and
Obesity American Academy of Pediatrics Policy
Statement
  • 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.

Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430
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Public Health Response Social-Ecological Model
(CDC)
Policy/Structure/Environment County/State
Policy/Structure/Environment - Schools
Social Norms Pub. Ed.
Individual Pub. Ed.
Social Professional Teaching Prof. Ed.
Policy/Structure/Environment - Communities
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Policy, Structure, Environment Communities
  • Promoting walkable communities
  • Introducing workplace wellness initiatives and
    incentives

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  • Developing teams at worksites and communities
    throughout the state
  • Supporting the Kauai Great Weigh Out that
    included nutrition education classes, incentives
    and team physical activity events

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Social Norms Public Education
  • Media TV, Radio, Theaters, Print
  • Partnerships Special Events
  • Website www.HealthyHawaii.com

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Policy, Structure, Environment Schools
  • 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

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Examples of food policy changes to 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
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Schools and Physical Activity
  • 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
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Social Professional Teaching 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

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School Based Weight Management Interventions
  • 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.

Obesity Research. 2003111313-1324
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Barriers 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

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  • Goals
  • 1. Increase access to healthy foods.
  • Increase opportunities for physical activity for
    Head Start children, parents, staff and
    communities.
  • 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.

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Summary Good 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
  • Its 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
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  • 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

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  • Implications for Future Research
  • Hawaii provides a unique opportunity to do more
    research about BMI measurement issues among
    Pacific Islanders and Asians
  • Providers need to acknowledge that cultural norms
    about body size exist among many Asian and
    Pacific peoples
  • We do not know enough about what different
    populations in Hawaii think of obesity (a
    western medical term) or body size relative to
    health
  • We need to find culturally appropriate ways to
    work with all diverse groups regarding achieving
    a healthy weight.

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MAHALO 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

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Study population for kindergarten
assessment N9,804 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.
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Percent obese among adults 20 years or older by
Community areas, Hawaii BRFSS combined year data
set, 2000-2003 (age-adjusted)
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