Childhood Obesity and Nutrition: An Ounce of Prevention

1
Childhood Obesity and Nutrition An Ounce of
Prevention

• Karen James, MD
• January 17, 2006

2
Todays presentation will

• Demonstrate the extent of the problem
• Explain how overweight/obesity occurs
• Share the consequences of this epidemic
• Health
• Economic
• Socioeconomic
• Describe the family physicians role in
  addressing this epidemic

3
Key Definitions

• BMI Body Mass Index is a calculation of height
  and weight.
• Adults BMI of 19-24 healthy, BMI of 25-30
  overweight, BMI of ? 30 obese
• Overweight
• BMI ? the 95th percentile
• At risk for Overweight
• BMI between the 85th - 95th percentile
• Childhood obesity Not used to describe an
  individual child. Childhood obesity refers to
  populations of children with a BMI at or above
  the 95th percentile.

4
Obesity Trends Among U.S. Adults BRFSS, 1987
(BMI 30, or 30 lbs overweight for 5 4
woman)
Source Behavioral Risk Factor Surveillance
System, CDC
5
Obesity Trends Among U.S. Adults BRFSS, 1989
(BMI 30, or 30 lbs overweight for 5 4
woman)
Source Behavioral Risk Factor Surveillance
System, CDC
6
Obesity Trends Among U.S. Adults BRFSS, 1991
(BMI 30, or 30 lbs overweight for 5 4
woman)
Source Behavioral Risk Factor Surveillance
System, CDC
7
Obesity Trends Among U.S. Adults BRFSS, 1993
(BMI 30, or 30 lbs overweight for 5 4
woman)
Source Behavioral Risk Factor Surveillance
System, CDC
8
Obesity Trends Among U.S. Adults BRFSS, 1995
(BMI 30, or 30 lbs overweight for 5 4
woman)
Source Behavioral Risk Factor Surveillance
System, CDC
9
Obesity Trends Among U.S. Adults BRFSS, 1997
(BMI 30, or 30 lbs overweight for 5 4
woman)
Source Behavioral Risk Factor Surveillance
System, CDC
10
Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI 30, or 30 lbs overweight for 5 4
woman)
Source Behavioral Risk Factor Surveillance
System, CDC
11
Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs overweight for 5 4
woman)
No Data 1519 2024 25
Source Behavioral Risk Factor Surveillance
System, CDC
12
Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI 30, or 30 lbs overweight for 5 4
woman)
(BMI ?30, or 30 lbs overweight for 54 person)
No Data 1519 2024 25
Source Behavioral Risk Factor Surveillance
System, CDC
13
Percent of overweight children in US(Overweight
BMI sex- age-specific 95 cutoff)
Source Dietz, 04
14
Washington State data

• 6 of 10 of adults are overweight or obese

Source CDC BRFFS, 2002
15
Washington State data

• Over 20 of high school students are overweight
  or at risk of becoming overweight
• 8 out of 10 overweight children will become obese
  adults

16
Why does overweight and obesity matter?
Its more than vanity
17
Associations between excess weight and disease

• Depression
• Poor self-esteem
• Eating disorders

X

• Stroke

X
X

• Heart failure
• Heart disease
• High cholesterol

• Sleep apnea
• Exercise intolerance
• Asthma

X
X
X
X

• Digestive problems
• Several cancers

• High blood pressure
• Kidney problems

X

• Osteoarthritis
• Joint problems
• Flat feet

• Insulin resistance
• Diabetes Type 2
• Polycystic ovary syndrome

X
X
X
X
Source Adapted from Lancet 02, CDC
18
Why it matters lifelong effects

• Overweight kids are at increased risk of
  premature death caused by heart disease as an
  adult
• 60 of overweight children and adolescents have
  already developed a risk factor for
  cardiovascular disease, including
• High blood pressure
• High cholesterol
• Insulin resistance

Source DiPietro, Dietz 04
19
Why it matters lifetime effects

• It is reasonable to expect that once adults,
  these kids will have a higher risk for earlier
  onset of the diseases associated with overweight,
  particularly
• Heart disease
• Type 2 diabetes
• Kidney disease

Source Sorof 04, Dietz NEJM 04
20
Why it matters lifelong effects

• Life-years lost from diabetes
• If diagnosed at age 40
• White
• male 10.1 yrs
• female 13.5 yrs
• Hispanic
• male 11.5 yrs
• female 12.4 yrs
• Black
• male 13.0 yrs
• female 17.0 yrs

Source Narayan et al. 2003
21
Why it matters lifelong effects

• Life-years lost from diabetes
• If diagnosed at age 10
• White
• male 16.5 yrs
• female 18.0 yrs
• Hispanic
• male 19.0 yrs
• female 16.0 yrs
• Black
• male 22.0 yrs
• female 23.0 yrs

Source Narayan et al. 2003
22
Why it matters Societal Burden

• Not only will these disease processes in
  childhood result in greater harm to the
  individual, it will add a considerable burden and
  cost to our society

Source Dietz, NEJM 04
23
Why it matters Academics

• Overweight children have significantly lower math
  and reading test scores compared to
  non-overweight children in kindergarten
• Children who are gaining weight rapidly have
  increased behavioral and learning difficulties

Sources Datar et al, Dietz 97
24
US Economic Cost

• Estimated cost of overweight and obesity in 1998
  is estimated to have been over 78 billion,
  nearly 10 of the US health expenditure
• Over 125 million is spent annually on hospital
  admittance caused by complications of childhood
  obesity

Source Finkelstien 03, Wang Dietz, Peds 02
25
Washingtons Economic Cost

• Annual estimate of medical expenditures
  attributable to obesity for Washington State
  alone Over 1.3 billion dollars
• 
  
• 
  Source
  Finkelstien 03

26
Why it matters Self-Image

• Overweight young children (5 years old)
• Develop a negative self-image
• Perceive themselves to have a lower cognitive
  ability
• Overweight adolescents
• Have a lower self-esteem associated with sadness,
  loneliness, and nervousness
• Are likely to participate in high risk behaviors

Sources Davison et al Peds 2001, Strauss et a
Peds 00
27
Why it matters Socioeconomics

• Once adults, overweight female adolescents
  compared to those of healthy weights, have been
  shown to
• Complete fewer years of schooling
• Have substantially lower household incomes
• Higher rates of poverty

Source Gortmaker et al. NEJM 93
28
How did this happen?
Weight gain
Energy Out
Energy In
29
How did this happen?

• Nature
• vs.
• Nuture

30
How did this happen?

• Is it genetics?
• The rates of overweight and obesity have
  increased in our adult and child populations at
  such a high rate in such a short time... Our gene
  pool hasnt evolved that fast.
• Did something change in our environment?
• It is plausible that something has changed in our
  environment that has made it easier for the
  population as a whole to gain weight.

Source Dietz 04
31
What has changed in our environment?

• The environment that we live in has changed in
  ways that have made it easier for us to eat more
  calories and expend less energy
• Increased time spent on sedentary activities TV,
  computer, video games, driving
• Less time spent doing physically active things
  e.g.- we work at desks instead of manual labor,
  we drive instead of walk, bike or run
• Portion sizes have increased
• Consumption of sugar and soft drinks has
  increased
• Increased availability and affordability of high
  calorie foods

Source Dietz 2004
32
What are kids eating?

• 1 in 4 adolescents drink more than 325 calories
  of soda per day
• Soda is the leading source of added sugar in the
  American adolescent diet
• Added sugars contribute 20 of the calories
  consumed by children

Source Bowman, Peds 04 FNS report to congress
01 CDC YRBS 01
33
What are kids eating?

• Each day, over 30 of children and adolescents
  eat fast food
• On days that children eat fast food, they consume
  substantially more calories and have a worse diet
  quality compared to days when they do not eat
  fast food.

34
What are kids eating?

• 2 of kids meet the Food Guide Pyramids
  recommendations for all 5 food groups
• Only 20 of kids eat the recommended 5 servings
  (minimum) of fruits and vegetables per day

Sources FNS report to congress 01, CDC YRBS 01
35
What are kids eating?

• When schools provide access to soft drinks and
  snack foods students are less likely to consume
  fruits, juice, milk and vegetables than schools
  who do not provide such access

Source Cullen 2000
36
The good news

• Overweight children dont have to grow up to be
  obese, sick adults
• When rapid weight gain is stopped in childhood,
  disease risk is greatly reduced

Source Sinaiko et al 99
37
What is the obesity solution?

• Prevention!
• Establish policies and environments that promote
  healthy eating and physical activity throughout
  our communities

38
Physicians have a pivotal role

• Assessing the home environment and promoting
  change
• Healthy habits are learned young - begin
  reinforcing them at home and in school
• Promote public policies to help prevent childhood
  obesity by supporting opportunities for healthy
  meals, physical activity and health education

39
Obesity Prevention Where do we start?

• Step 1 Prenatal care
• Step 2 Breastfeeding promotion
• Step 3 Train parents how to feed their children

40
Prenatal Care

• Maternal weight is an important predictor of
  later obesity in children
• Encourage breastfeeding
• Intent to breastfeed is associated with increased
  initiation and duration of breastfeeding
• Lower incidence of obesity in breastfed infants

41
Obesity Threatens Breastfeeding

• Obesity before and during pregnancy resulted in
• Less initiation and shorter duration of of
  breastfeeding
• Increasing obesity may threaten recent gains in
  breastfeeding prevalence

Source Pediatric Pregnancy Nutrition
Surveillance Surveys
42
From birth to 24 months, the child assumes the
eating habits of the family.

• The Feeding Infants
• And Toddlers Study (FITS)
• SourceDwyer, 2004

43
The 12 Well-Child Visits
4
11
1
12
3
7
9
5
10
2
6
8
Anticipate problem feeding and activity practices
44
Newborn Visit

• Support breastfeeding by building skills and
  offering resources
• Iron-based formulas only
• Review hunger and satiety cues
• Babies regulate their own intake
• Crying is not always hunger
• It is normal for 1-3 month old babies to cry up
  to 3 hours per day

45
Two-Month Visit

• Infant Feeding
• Set expectations
• Intake will increase to 24-28 oz/day over the
  next 2 months
• Provide 4 oz four to six times per day
• Emptying the bottle encourages overeating
• No cereal, no baby food, no juices
• Nothing added in the bottle

46
Not all Crying Needs Food

• Learn to interpret the infants cries
• Satiety cues between 4-12 weeks
• Turns head away or releases nipple
• Falls asleep
• Comfort the baby
• Rocking, massaging, cuddling, listening to
  music, driving

47
Physical ActivityTwo Months

• Minimize stationary devices
• Use crib mobiles
• Encourage reaching, kicking, stretching, and
  belly play time
• No T.V.

48
4-Month Visit

• The addition of cereal
• No solids until developmentally ready to use a
  spoon, usually 4-6 mos of age
• Cereal only with a spoon, not in the bottle
• Start a single grain, iron-fortified cereal
• Portion increase to 1-2 tablespoons twice daily
• First baby food vegetables at 6 mos

49
Recommendations for Iron

• Healthy People 2010 reduce iron-deficiency
  among children aged one to two years to 5
• AAP Committee on Nutrition
• Supplement breastfed infants with iron
• Iron-fortified formula in the first 12 months
• Iron fortified infant cereals and grains, as well
  as meats, are important sources of iron,
  especially for infants who continue to breastfeed
  beyond 6 months of age

50
Excessive Juice is a Risk for Obesity

• Both short stature and obesity are tied to
  excessive intake of juices
• Only 100 juice
• Only after 6 months of age
• Only from a cup
• Maximum of 4-6 oz per day

51
Physical ActivitiesFour Months

• Non-restrictive play
• Belly play time
• Sits with support
• Reaches and holds objects
• Play gyms
• No T.V.

52
Six-Month Visit

• Start vegetables and offer first at each meal
• Add one new food every 4-7 days
• Portion sizes
• Cereal 2-4 tablespoons twice/day
• Vegetables 2 tablespoons twice/day
• Fruits 2 tablespoons twice/day
• 100 juice, max 4-6 oz/day

53
Common Early Feeding Traps

• Anticipate daily milk intake will fall as babys
  food intake increases
• Avoid combo dinners and baby desserts
• The extrusion reflex is normal and does not mean
  that the baby doesnt like the food
• New foods may require multiple presentations
• Focus on new eating experiences and skills

54
Feeding the Baby

• Infants innately prefer sweet and salty
• Infants may reject bitter and sour
• Infants tend to resist new foods (neophobic)

55
Implications

• More than 10 exposures may be needed to establish
  a new food
• Children like and eat what is familiar
• Parental eating habits influence the babys
  choices at this age

56
Promote Vegetables

• 27 of 9-11 month old and 23 of 12 month old
  infants do not consume vegetables food
• Less than 10 of toddlers eat dark green
  vegetables
• Consumption of deep yellow vegetables decreases
  from 39 at 9 months to 14 at 18 months

Source Fox et al. 2004
57
Physical Activities Six Months

• Minimize stationary devices
• Sits without support
• Starting to crawl
• First signs of independent mobility
• No T.V.

58
Nine-Month Visit

• Offer variety finger and table foods
• New food types and textures
• Veggies fruits at every meal
• Establish a variety of meats
• Introduce the cup
• Review choking hazards
• Never use food as reward or bribe

Aim to Develop Self-feeding Skills
59
Caution Choking Hazards!

• Nuts
• Grapes
• Apple chunks, slices
• Sausages

• Popcorn
• Round candies
• Hard chunks of uncooked veggies
• Hot dogs

Some foods are dangerous because an infant cant
chew or coordinate swallows and lacks a full set
of teeth.
60
Physical ActivitiesNine Months

• Begins to hold cup
• Spoon feeds with help
• Encourage crawling
• Pulls to stand
• No T.V.

61
Twelve-Month Visit

• Introduce regular milk
• Whole milk - not skim or 2
• Taper from 24 oz. to 16 oz. per day
• All fluids from a cup
• Continue to wean from the bottle
• Fluids
• Water is best for extra fluid
• Avoid sweetened drinks

62
Twelve-Month Visit

• Solid foods
• Emphasize eating skills and experiences
• 3 regular meals and 2-3 planned snacks
• Avoid grazing throughout the day
• Emphasize vegetables and fruits
• Appropriate serving size is 1/2 cup of fresh (or
  1/3 cup canned) fruits/vegetables per serving per
  meal

63
Physical Activities Twelve Months

• Push toys
• Walking
• Running
• Unrestricted play
• Never inactive for more than 60 minutes
• No T.V.

64
15- and 18-Month Visits

• No more bottle
• Whole milk from a cup in 4-oz servings
• Milk limit 16 oz/day
• 100 fruit juice 6 oz/ day
• No sippy cup
• Snack times
• 2-3 planned snacks per day
• Watch portion size, nutritional value
• Meal times
• 3 meals per day
• Variety of color, texture, and tastes
• New foods at the start of the meal
• 10 exposures of each new food
• No dessert

65
15 and 18-Month Visits

• Meals are social occasions
• Establish family meals
• Adults should act as role models during meals
• Milk with meals
• Limit desserts, avoid candy
• T.V. off

66
Safe Snacks

• Cheese
• Yogurt
• Saltines
• Graham crackers
• Pretzels
• Bagel, bread, toast
• Whole wheat crackers

• Fruit (watch for seeds and peels)
• Fruit smoothies
• Steamed veggies
• Puddings
• Unsweetened cereals
• Mashed / finely cut meats or fish

Avoid the habit of snacking in the car and on the
go.
67
Fiber

• Daily allowance age plus 5 grams
• 2-year old 2 5 g 7 g day
• Emphasize whole grains to boost fiber
• Ready-to-eat cereals (unsweetened)
• Yeast breads
• Corn and other chips
• Hot breakfast cereals
• Crackers
• Popcorn

68
Two-Year Visit

• Meals All 5 food groups daily
• Begin to decrease the fat content
• Switch to 2 milk, have at every meal
• Portion size at home and away 1 Tbsp per year of
  age or ¼ of an adult portion
• Plate and cup size matters
• Food jags are typical normal
• A variety of textures, colors, flavors
• Dont bias your childs food choices

69
Physical Activity Two Years

• Active play with other children
• Marching
• Jumping
• Climbing
• Limit T.V. to 1-2 hours per day
• Get outside

70
Three and Four-Year Visits

• Meal times
• Planned meal snack times
• Turn off T.V.
• Move toward skim milk
• Variety fruits, vegetables, whole grains
• Limit potatoes
• Avoid eating in front of the T.V.
• Limit screen time to 1-2 hours per day
• Help child choose what to watch

71
Physical ActivityThree and Four Year Olds

• Throwing and bouncing balls
• Running and jumping
• Ride tricycle
• Structured play 60 min/day
• Unstructured play 30 min/day

72
Five and Six-Year Visits

• Daily diet suggestions
• A nutritious breakfast every day
• School lunch or quality brown bag lunch
• Milk and dairy at every meal
• Fruits and vegetables in abundance
• Plan healthful snacks for after-school time
• Limit soft drinks and fruit drinks

73
Eating Out with Your Child

• Include at least two different food groups
• Limit sweets to one per meal
• Only one fried food per meal
• Assure that all foods, especially desserts and
  drinks, are child-sized

Source Satter 1986
74
Eating Out with Your ChildControl Portion Sizes

• Share your meal or order a half-portion
• Order an appetizer as an entrée
• Take half your meal home
• Stop eating when you feel full
• Avoid super-sized sweetened drinks
• When traveling, pack nutritious snacks

75
Physical ActivityFive and Six Year Olds

• Unstructured play at least 30 min. per day
• Structured play at least 60 min. per day
• Plan outdoor time and reading time daily
• Limit screen time to 1-2 hrs per day
• Computers
• Games
• T.V.
• Movies

76
Conclusions...

• Childhood obesity has serious health, economic
  and socioeconomic effects.
• Family physicians are uniquely positioned to
  prevent childhood obesity
• Prenatal counseling on weight gain and
  breastfeeding
• Teaching parents how to promote healthy diets
  eating and physical activity
• Advocating for public policies which promote
  healthy eating and physical activity