Childhood Obesity and the Modern Lifestyle: Implications for Future Generations

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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

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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
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Definition of Obesity

• A chronic preventable disease
• Obesity is defined as excess body fat (not simply
  excess weight)

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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 Childrenand 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)
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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
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Epidemiology of Overweight in Kids in General
U.S. Population
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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).

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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

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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

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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

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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
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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)

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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
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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, EnvironmentCommunities

• 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 NormsPublic Education

• Media TV, Radio, Theaters, Print
• Partnerships Special Events
• Website www.HealthyHawaii.com

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Policy, Structure, EnvironmentSchools

• 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 ProfessionalTeaching 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)