Pat Crawford, DrPH, RD

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Health Disparities

Food Insecurity
Obesity
Connecting the Dots
Pat Crawford, DrPH, RD Adjunct Professor,
Nutrition Specialist and Co-Director Center for
Weight Health University of California at
Berkeley
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• OUR MISSION
• Provide leadership for the development of
  interdisciplinary science-based solutions to
  weight, health and hunger related problems
• visit http//nature.berkeley.edu/cwh/index.html

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CWH Conducting epidemiologic studies

• Longitudinal development of obesity in children
• Development of eating patterns in Black and White
  girls
• Effects of pregnancy on adolescent growth and
  health
• Childhood factors associated with the development
  of peak bone mass in young women

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CWH Conducting intervention studies

• Sodas out of Schools (SOS) a high school
  beverage intervention
• Evaluation of Californias SB 19 Pupil
  Nutrition Act an elementary and middle school
  nutrition physical activity intervention
• Prevention of type 2 diabetes in at-risk African
  American children a collaboration with the YMCA

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CWH Supporting community efforts

• Developing Children Weight What
• communities can do how-to kit
• Supporting the development of Videonovelas
• and Fotonovelas Fit Families For parents
• who want the most for their children
• Creating Lets Get Moving materials for
• parents and teachers of pre-school aged children
• Providing evaluation support for Department of
• Education and WIC
• Working with local Cooperative Extension on
  outreach research

                                         
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CWH Synthesizing literature

• Pediatric Overweight A Review of the
  Literature (CA Dept. of Health Services)
• Determinants of Energy Imbalance
• (CDC-SIP-07) soon to be published by CRC
  Press
• Prevention of Type 2 Diabetes in Youth
• Prevention and Treatment of Childhood Obesity
  (An evidenced-based position paper for the
  American Dietetic Association) in press

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CWH Providing resources

• Website http//nature.berkeley.edu/cwh/index.html
• Listserv click on website to join
• Lectures and Conferences

Mark your 2007 Calendar! January 2326,
2007 California Child Obesity Conference Marriott
Hotel, Anaheim http//www.cce.csus.edu/cts/co07/in
dex.htm
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Definitions

• BMI (metric) weight (kilograms)/height2
  (meters)
• BMI (American) weight (pounds)/height2 (inches)
  x 703

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Definitions for Children
95th percentile Overweight
85th percentile At risk for overweight
5th percentile Underweight
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Today we are going to play Fact or Fiction
The rules are simple Will I say, Fact or
Fiction? If it is a Fact wave your arms If it
is Fiction stomp your feet
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Today for the first time, there are almost as
many overweight children as there are overweight
adults
Fact or Fiction?
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Stomp your feet Fiction
There are over 4 times as many overweight adults
as there are overweight children.
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But we are very concerned about childhood because
pediatric overweight has increased by about 300
in the last 30 years.
Fact or Fiction?
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Wave your arms Fact
Overweight has tripled for children adolescents.
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As a comparison Changes among adults
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The risk of pediatric overweight is similar for
low income children regardless of race or
ethnicity.
Fact or Fiction?
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Stomp your feet Fiction Rates of overweight in
young low income children are significantly
greater for Hispanic and American Indian
children. (The disparity is even greater when
analyses are not adjusted for income.)
PedNSS 2001 data
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Racial ethnic disparities in child obesity
rates are getting larger.
Fact or Fiction?
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Disparitiesare increasing
Wave your arms Fact
SOURCE Centers for Disease Control and
Prevention, National Center for Health
Statistics, National Health and Nutrition
Examination Survey.
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In the last 30 years

• Obesity has increased in
• Both sexes
• All age groups
• All racial/ethnic groups
• All income levels

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• However, those at the
• lowest income levels have increased the most.

Fact or Fiction?
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Wave your arms Fact

• Overweight has replaced malnutrition as the most
  prevalent nutritional problem among the poor.

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Why is obesity increasing?
and why is obesity increasing faster in
low-income and food insecure families?
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Sociodemographic factors?
Genetics?
Biologic factors?
Environmental changes?
Economics?
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Genetics?

• Heritability of body fatness is believed to be
  about 65. This is similar to heritability of
  schizophrenia (68) and greater than that of
  breast cancer (45)

Tuomilebb, NEJM 2001
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Sociodemographic Factors?

• Household Income
• Parental Education
• Family Composition
• Acculturation
• Food Insecurity

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• Obesity risk associated with low income
  overshadows effects of race and ethnicity.

Fact or Fiction?
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Differential association between household income
and overweight by race
Stomp your feet Fiction
Patterson Crawford, 1997
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Acculturation

• Second- and third-generation Asian and Mexican
  American children are more likely to be
  overweight than first generation children.

Fact or Fiction?
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Rates of adolescent obesity for immigrants
Wave your arms Fact
Obesity defined as 85th percentile
Source Popkin BM, Udry JR. Adolescent Obesity
Increases Significantly in Second and Third
Generation U.S. Immigrants The National
Longitudinal Study of Adolescent Health. J Nutr
1998 Apr128(4)701-6.
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Food Insecurity

• Food insecurity is a risk factor for obesity in
  low income adults and children.

Fact or Fiction?
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Food insecurity is associated with obesity in
women, but not in men or children.
Stomp your feet Fiction
Townsend M, 2001
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Biologic Factors?

• Those exposed to inadequate or fluctuating food
  consumption generate adaptive methods to achieve
  a high level of efficiency in the use of energy
  and deposition of fat.
• Those malnourished in early pregnancy may have
  impaired mechanisms for handling nutrients, which
  leads to a greater susceptibility to obesity.

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Environment Factors?

• Food availability
• Beverage shifts
• Portion size shifts
• Food ads
• Automobiles
• Neighborhood design
• TV video games
• Sedentary jobs
• Etc.

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Secular Trend of Kcal
2800
2500
Calories per person per day
2000
Adapted from Putnam et al. Food Review, 2002.
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How is this happening?
1 oz
6 oz
8 fl oz
32-64 fl oz
16 cups
3 cups
Trends from 1957-2001 (Nicklas, 2001)
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Secular Trends in Sweetened Beverage Consumption
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Television hours are increasing
NHANES III, 1988-1994 8-16 year old children
adolescents Crespo et al. Arch Pediatr
Adolesc., 2001.
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Automobile time is increasing
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But why are low-income persons at higher risk for
obesity?

• First, energy-dense foods cost less, encouraging
  a shift to foods that provide the maximum
  calories for the least cost among low-SES
  households

(Drewnowski 2004)
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• Second, the food industry markets mass,
  low-quality products with higher fat and sugar
  content to sectors with less purchasing power.

(Aguirre P, Obesity and Poverty, 2000)
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• Third, a healthy basket of food has been found to
  cost more in disadvantaged areas than in affluent
  areas

(Acheson D, 1998)
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• Fourth, children from low income families were
  less likely to participate in physical activities
  in school PE, as well as programs outside of
  school.

• (Sallis, 1996)

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• Fifth, adolescents from low income families
  participate in less vigorous physical activity,
  even after controlling for gender and
  race/ethnicity

(Lowry, 1996)
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Economists say that technological change has

the
of consuming calories
and
the
of expending calories
Fact or Fiction?
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Wave your arms Fact

The
of consuming calories has decreased, while
The
of expending calories has increased.
(Phillipson Posner, 1999)
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What can be done?
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First

• Understand that the poor need
• more nutrient dense food
• to prevent malnutrition,
• to promote health,
• to prevent hunger, and also
• to prevent obesity.

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Second

• Understand that individual choices are made in a
  community or environmental context.
• Individuals will chose the
• tastiest,
• most fun,
• cheapest, and
• most convenient options

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• Policy makers must help promote healthy choices
  which are fun, cheap, and convenient.

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Actions for anti-poverty, anti-hunger, and
anti-obesity advocates

• Find ways to incorporate nutritious foods and
  nutrition education in what is distributed by
  food banks and other assistance agencies
• Ensure that programs linking low-income groups to
  healthy foods (e.g. WIC Farmers Market Nutrition
  Program) are funded, promoted, and used
• Ensure that the school breakfast and lunch
  programs meet nutrition standards and are utilized

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• Support grass-roots community efforts to healthy
  environments.
• Urge stakeholders in each sector of society
  (schools, worksites, built environment,
  transportation, advertising, media, food
  beverage supply system, insurance health care,
  community groups, and government) to play a role
  in the solution.
• Gather, share, and promote best practices. (CWH
  website Governors Summit on Obesity Resource
  Kit, September 2005)
• Use the Spectrum of Prevention to provide a
  multi-level approach to obesity prevention.
• Prevention Institute

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Spectrum of Prevention
Influencing Policy and Legislation
Changing Organizational Practices
Fostering Coalitions and Networks
Educating Providers
Promoting Community Education
Strengthening Individual Knowledge and Skills
Prevention Institute
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• Remember
• An environmental versus an individual approach to
  prevention of obesity and hunger
• reaches the hard-to-reach population
• is more cost-effective
• is more sustainable

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Together we have the capacity to improve the
health status of our population and reduce
obesity, poverty, and hunger rates.
Fact or Fiction?
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Wave your arms Fact

• We have the capacity
• and the will is building!
• http//cnr.berkeley.edu/cwh