Childhood Obesity: Strategies to Halt a Growing Epidemic (and a few words on trans fats)

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Childhood Obesity Strategies to Halt a Growing
Epidemic(and a few words on trans fats)

• Lynn Silver, MD, MPH
• Assistant Commissioner and
• Mary T. Bassett, MPH, MD
• Deputy Commissioner
• Health Promotion and Disease Prevention
• New York City Department of Health and Mental
  Hygiene
• US Conference for Mayors
• Washington DC
• January 25, 2007

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Overview

• The New York City Experience
• Building a healthy environment
• Access to healthy foods
• Opportunity for physical activity
• Regulatory Approaches
• Physical Activity and Nutrition Requirements in
  Day Care
• Calorie Labeling
• Restriction of Trans Fat

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Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1986
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1987
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1988
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1989
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1991
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1992
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI 30, or 30 lbs overweight for 5 4 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2003
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2004
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
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Obesity Begins EarlyOnly Half of NYCs
Elementary School Children Are at a Healthy Weight
More than 4 in 10 are overweight or obese in
Grades K-5
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Percentage of High School Students Who were
Overweight (selected U.S. states)YRBS, 2005
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Why worry about childhood obesity?

• Strong predictor of obesity in adulthood
• Major early risk factor for much of adult
  morbidity and mortality diabetes has doubled
• Health problems associated with obesity
• Type 2 diabetes (hyperinsulinism, insulin
  resistance, IGT)
• Cancer
• CVD (hypercholesterolemia, dyslipidemia, htn)
• Depression, low self-esteem
• Asthma, sleep apnea
• Osteoarthritis

SOURCES American Academy of Pediatrics, 2003
Dietz Gortmaker, 2001
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Policy Approaches to Address Obesity

• Obesity is not just a problem of the individual,
  but also a problem rooted in environmental and
  community factors
• 2001 Surgeon Generals Call to Action to Prevent
  and Decrease Overweight and Obesity declared
  obesity a national priority

SOURCES U.S. DHHS, 2001 Galvez, Frieden
Landrigan, 2003
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The New York City Experience

• Building a healthy environment
• Access to healthy foods
• Opportunity for physical activity
• Regulatory Approaches
• Day care physical activity and nutrition
• Calorie labeling
• Trans fat (addresses heart disease risk)

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Make it easier to make healthy choices!

• Schools
• More physical activity
• No soda/vending machines
• 1 milk
• Day Care Centers
• More physical activity
• No sugar sweetened drinks, 1 milk only
• Limited TV
• Community Environment
• Shape-Up programs in parks
• Access to fresh fruits and vegetables
• Improving the built environment

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Overall Daycare Population in NYC
Day Care Facility Type Total Facilities Setting Law/ Regulation Approx. Capacity
Group Day Care (GDC) Permit 2,072 Non-residential NYC Health Code (Article 47) 98,696
Group Family Day Care (GFDC) License 2,232 Home of an unrelated family 18 NYCRR (part 416) 30,742
Family Day Care (FDC) Registration 3,775 Home of an unrelated family 18 NYCRR (part 417) 103,942
School Age (SA) Registration 1,192 Non-residential 18 NYCRR (part 414) 121,966
TOTAL, all facility types 9,271 355,346
2006 data 2002 data
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Group Day Care Population in NYC

• There are 2,072 Group Day Care programs
• Serve about 100,000 infants, toddler and early
  childhood (ages 2 to 5).

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Daycare regulations and the NYC Health Code A
Bit of History

• First day nursery in US opened in NYC in 1854
• Day care was regulated within the Sanitary Code
  of the City of New York, beginning approx. 1910
• Compliance with these regulations was not
  mandatory until 1943.
• As a side note, the regulations of 1943 required
  2 hours of outdoor play and a hot meal at noon
  and a "daily allowance of at least a pint of milk
  a day".
• The Health Code was adopted March 23, 1959.
• New requirements to address obesity effective
  January 2007

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Day CarePhysical ActivityRegulations

• Establishes a required minimum number of physical
  activity minutes daily
• For ages 12 mos. and up, at least 60 min./day
• For ages 3 and older, at least 30 min. of that
  time must be structured guided activity
• SOURCES CDC National Association for Sport and
  Physical Education

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Day CareLimits on TV

• Establishes limits on TV video viewing
• No TV, video and other visual recordings for
  children under two years of age
• For ages 2 and older, limits TV, video and other
  visual recordings to no more than 60 minutes per
  day of educational programs or programs that
  engage child movement
• SOURCES American Academy of Pediatrics
  Institute of Medicine

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Day CareNutrition Standards

• Provide guidance on
• Appropriate kinds of foods beverages - no
  sugar sweetened beverages allowed. 1 milk only
  after age 2.
• Appropriate portion sizes for children
• (while remaining consistent with federal CACFP
  policy for meal snack reimbursement)

SOURCES Child and Adult Care Food Program U.S.
Dietary Guidelines for Americans, 2005
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Implementation/Support

• Nutrition training efforts
• to day care inspectors
• to nutrition staff in community through the
  bureau of daycare
• Educational materials disseminated to children
  and parents through daycare staff
• SPARK training in early childhood settings

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SPARK!

• Since 2003, DOHMH has partnered with the Sports,
  Play and Active Recreation for Kids! (SPARK)
  program
• Goal train and equip all daycare centers (17
  trained so far), schools, K-2 teachers, and
  after-schools in highest risk communities
• Since November 2003, SPARK training and equipment
  provided to over 2500 staff from more than 600
  sites.

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Healthy Bodega Initiative

• Brooklyn survey Access to healthy foods
• Conducted among 2 of the poorest neighborhoods in
  NYC
• 84 of food stores are bodegas
• 6 of food stores are supermarkets
• 28 provide limited fresh fruit, if any at all
• 33 sell reduced fat milk, but at higher prices
• 6 of bodegas sell any type of leafy vegetables
• Health food access is extremely poor
• Similar findings in other high risk areas

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Healthy Bodega Initiative

• Healthy Bodegas Initiative
• 1 milk campaign
• Partnership with bodegas to stock 1 milk, offer
  discounts and distribute health information
• Fruits vegetables campaigns (Pilot project)
• Bodega owners are provided with a free shipment
  of pre-packaged ready-to-eat apples and carrot
  snacks, if interested they can re-order from
  distributor
• Bodegas received a toolkit containing bi-lingual
  promotional items
• HD will conduct outreach and education to local
  schools, day cares and WIC centers

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NYC Health Code Calorie Labeling

• Requires certain FSEs to post calorie content on
  menu boards and menus next to each menu item
• Applies to FSE who provide standardized menu
  items and for which calorie information is
  publicly available on or after March 1, 2007
• Does not apply to FSEs that have not made calorie
  information publicly available
• FSEs have six months to comply - July 1,2007

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Partial Phase-Out of Trans Fat in
Restaurants Amendment to the NYC Health Code
Approved December 2006 Phase I July 2007
Frying Oils and Spreads Phase II July 2008 -
All other uses
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Trans Fat Increases Heart Disease Risk 5 or
more of cardiac events due to trans fatMore
Dangerous than Saturated FatNo one will miss it

• Good (HDL) Bad (LDL)
• Cholesterol Cholesterol
• Trans fat
• Saturated fat

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Major Food Sources of Artificial Trans Fat for
U.S. Adults
Data Source http//www.fda.gov/fdac/features/2003
/503_fats.html
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Trans Fat Use Did Not Decline Despite Voluntary
Campaign
Health Bulletin to 200,000 people
9,000 FSEs received additional info
Info tools to food suppliers and to gt20,000 NYC
restaurants
Restaurants Using Trans Fat in Oils and
Spread Where Use Could Be Determined
7,800 restaurant operators trained
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Effective Public Health Requires Government Action

• Precedents
• Removing Lead like trans fat it was
  unnecessary, repleaceable, and is not missed
• Adding Folate
• Seatbelt requirements
• Limit exposure to second-hand smoke
• Individual action alone is not enough
• Cant tell if food contains transfat
• Poor judgement of calorie content
• For many, exercise opportunities are limited
• Access to healthy foods is not a personal choice

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We are getting a lot of questions

• California
• Florida
• Connecticut
• Massachusetts
• New Jersey
• Pennsylvania
• Washington State

• Ohio
• Oregon
• Michigan
• Washington DC
• Illinois
• West Virginia
• Virginia

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Strategies for Consideration

• Create the Environment
• Increase access to healthy foods for everyone
• Target poor, high risk areas/neighborhoods
• Improve public procurement
• Regulate improve food service in schools, day
  care centers, after-school, camps
• Encourage more drinking of water and no use of
  sugar sweetened beverages
• Increase access to physical activity
• Structured physical activity and facilities in
  schools, communities, workplace
• Built environment modifications provides
  opportunity for safe and convenient exercise
• Calorie labeling
• Soda Tax

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Thank you!