Dr' Marla Shapiro

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Dr. Marla Shapiro CCFP. MHSc, FRCP,
FCFP Associate Professor, University of
Toronto CTV Medical Consultant Challenging Our
Kids to be HEALTHY and FIT
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Globesity

• A complex condition, one with serious social and
  psychological dimensions, that affects virtually
  all age socioeconomic groups and threatens to
  overwhelm both developed developing countries
• - World Health Organization (WHO)
• WHO facts
• gt 1.2 billion people worldwide are overweight
• 250 million are obese
• 7 of the adult population worldwide are affected
• 115 million are obese in developing countries

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Obesity Trends Among Canadian AdultsHPS, 1985
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among Canadian and U.S. Adults,
2000
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Obesity Trends Among Canadian and U.S. Adults,
2004
10-14 15-19 ?20 ?25
?30
AH Mokdad, CDC M Shields, Statistics Canada, 2005
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Prevalence of Overweight Obesity 6 Canadian
Children 2004 (2-17yrs)
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Prevalence Overweight Obesity Canadian Children
by Race (2004)
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Socioeconomic Status Obesity in Canadian
Children
plt.01
PREVALENCE
SOCIOECONOMIC STATUS
1994 National Longitudinal Survey Children and
Youth (NLSCY)
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Provincial Overweight Obesity 2004 (children
aged 2-17)
50
PREVALENCE
0
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Canadian Reports on Childhood Obesity A sample

• Sheila Basrur (Healthy Weights Healthy Lives
  Report of the Chief Medical Officer of Health)
• Kellie Leitch (Reaching for the Top Report of
  the Advisor on Healthy Children Youth)
• The Provincial Council of Child Health
• Paediatric Complex Care Coordination Expert Panel
  Report. 
• Healthy Active Living Committee /Canadian
  Paediatric Society
• Canadian Obesity Guidelines CMAJ April 2007
• Canadas Food Guide released April 2007
• Addressing Childhood Obesity The Evidence for
  Action. Institute of Nutrition, Metabolism
  and Diabetes, CIHR CAPHC, PCC 2004
• The cost of obesity in Canada. Birmingham CL et
  al CMAJ 1999160483-8
• Report of the Standing Committee on Health Rob
  Merrifield, MP Chair MARCH 2007 39th
  PARLIAMENT, 1st SESSION

REACHING FOR THE TOP A Report by the Advisor
on Healthy Children Youth
Dr. K. Kellie Leitch
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Call for action preventing and managing the
expansiveand expensive obesity epidemicLau D,
CMAJ FEB. 23, 1999 160

• Because genetic heritability accounts for only
  2530 of the obesity phenotype prevention and
  treatment should logically be directed mainly at
  environmental factors (social, behavioural and
  cultural) as principal determinants...
• The overall goal for obesity management is to
  reduce the health risks, which begin to lessen
  even with modest weight loss, long before a
  desirable body weight is achieved.

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2004 Chief Medical Officerof Health (Dr. Sheila
Basrur) ReportHealthy Weights, Healthy Lives
in the 21st century, our environments
increasingly are responsible for tipping us into
overweight and obesity. We are now living in
obesogenic environments, communities,
workplaces, schools and homes that actually
promote or encourage obesity We have made our
generation the most sedentary in history.
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Brief to Standing Committee on Health October
19, 2006Dr. Claire LeBlanc Chair, Healthy Active
Living CommitteeCanadian Paediatric Society
The responsibility to encourage physical
activity and good nutrition among children and
youth falls on all of our shoulders parents,
physicians, policy makersall Canadians who care
about the health of our kids today and the health
of our society tomorrow.
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Provincial Child Health Symposium
ProceedingsJanuary 14, 2008Provincial Council
for Childrens Health

• 750,000 of Ontarios children are overweight or
  obese and the prevalence is increasing at an
  alarming rate.
• Preventing and treating child obesity must be a
  collective effort ... MJ Haddad

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Reaching for the TopA Report by the Advisor
onHealthy Children Youth, Dr. K. Kellie Leitch

• we are doing surprisingly poorly when compared
  to other OECD countries in measures of the health
  and wellness of children and youth.
• Canada ranks 27th in childhood obesity
• in todays increasingly competitive global
  economy, we must invest in the health and
  wellness of our children and youth ...

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The Village What do we need to change?

• As parents/adults
• We model sedentary behaviour
• We model excess eating
• We dont know about hunger and fullness
• We model dieting behaviour

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The Village What do we need to change?

• As a society
• We value work over physical activity
• We arrive home and sit (often eat) in front of
  the tv
• We drive our kids to school when it is a 5 or 10
  minute walk
• We devalue the opportunity to play outside

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The Village What do we need to change?

• As a society
• We close schoolyards at 4 pm
• We dont adequately support breastfeeding
• We think more is better (eg larger meal, larger
  pop bottle)

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The Village What do we need to change?

• As school systems
• We keep our kids in from playground if they are
  behind in their work
• We dont value physical education as equal to
  academics in our kids lives
• We drop extracurricular activities in any fiscal
  crunch

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The Village What do we need to change?

• As school systems
• We give our kids 15 minutes to eat lunch
• We often reward our younger kids with food or
  candy for performance
• We load on so much homework there is no time for
  play

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The Village What do we need to change?

• As societal policy
• We close city pools for lack of funding
• We give up our neighbourhoods to a perceived lack
  of safety
• We advertise unhealthy foods incessantly to our
  kids (tv, schools,etc)

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The Village What do we need to change?

• As societal policy
• We build neighbourhoods without sidewalks or safe
  places to walk, play, or ride a bike
• We regulate neighbourhood activities out of
  existence (eg street hockey)
• We price healthy food as more expensive than
  unhealthy foods

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Can we even detect the risk

• Parents cannot see obesity in their own children
• 18.3 vs 29.9 (61.2 of the time)
• Are parents aware that their children are
  overweight or obese? Do they care?
• Can Fam Physician 2007531493-1499 Meizi He MD
  MSc PhD Anita Evans

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Can you see risk?

• This boy is 3 years, 3 weeks old.
• Is his BMI-for-age
• - gt85th to lt95th percentile at risk
  for overweight?

Photo from UC Berkeley Longitudinal Study, 1973
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Plotted BMI-for-Age
Measurements Age3 y 3 wks Height100.8 cm
(39.7 in) Weight18.6 kg (41
lb) BMI18.3 BMI-for-age gt95th
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Genetics of Obesity
Is it Genetic? are we doomed?
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Health Consequences of Childhood Obesity
Insulin resistance
Depression
Hypertension
Dyslipidemias
?
Type II diabetes
Fatty Liver
Asthma
Poor self esteem
Polycystic ovary syndrome (PCOS)
Sleep apnea
Eating Disorder
A physician/clinician has to screen for these
disorders in any obese child
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Type II Diabetes

• Up to 50 newly diagnosed diabetics in childhood
• Obesity hallmark
• Obese children
• 25 impaired GTT
• 4 silent type II diabetes
• Insulin resistance

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Dyslipidemia

• Bogalusa Heart Study
• 60 of 9167 obese children had one CV risk factor
  
• ? BP, dyslipidemia, insulin resistance
• obese 2.4 - 7.1x more likely than non-overweight
• ? cholesterol, triglycerides, /- LDL
• ? HDL
• Childhood obesity most common cause of secondary
  hyperlipidemia
• Hyperlipidemia may improve with weight loss

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High Blood Pressure

• 3 million US youths
• Associated with obesity
• Overweight children
• RR ? diastolic BP 2.4
• RR ? systolic BP 4.5
• Tracking adolescence ? adulthood established

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Sleep Apnea

• 35 obese children snore regularly (? boys)
• 26 obese kids sleep disordered breathing
• Obese kids-sleep apnea
• Poor sleep gt obesity

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What Can Be Done?

• Activity is absolutely vital in a healthy
  lifestyle as it not only contributes to healthy
  energy balance, but also to better mood, fitness,
  academics, and disease prevention. 
• The best activity for a child to do is the one
  that they will enjoy and therefore actually do.

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What Can Be Done?

• A child who understands both their hunger and
  fullness signals will be able to govern their own
  eating to within reasonable amounts.

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What Can Be Done?

• SUPPORT
• Sessions must be carried out with sensitivity
  to ensure no negative body image contribution,
  and to diminish any that exists

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Nutrition
Key Concepts Hunger and Fullness Activity as a
Normal Lifestyle Best activity to do School and
Environmental Scan
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TRAFFIC LIGHT DIETRed, Yellow, Green System
for Weight Management GROUPING OF FOODS BASED
ON CALORIC/NUTRIENT DENSITY
Adapted from L. Epstein, Traffic Light diet for
use in Prader Willi Syndrome By Karen Balko, RD,
North York General Hospital
Exchange system. Assignment of average calories
per food group. Concrete approach to dietary
control. Helps with reducing food obsession/anxie
ty in special needs populations.
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• Encourage your child to drink water instead of
  juice. Even juice that is labelled unsweetened
  can have as many calories as soft drinks. Set a
  limit on juice and soft drinks. Aim for no more
  than 4 to 8 oz a day, depending on your childs
  size and weight.

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MAKING SUCCESSFUL LIFESTYLE CHANGES

• Talk about motivation of the child/teen/family
• Identify areas of interest in making change.
• Be patient and expect that progress will take
  many small steps over time.
• Encourage small steps in making lifestyle
  changes.
• Be positive and encouraging.

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MAKING SUCCESSFUL LIFESTYLE CHANGES

• Avoid focusing on the weight as an indicator for
  success. Always focus on the positive changes in
  their lifestyle they have made in follow-up, even
  if they have gained weight.
• Involve the child/teen/family in deciding their
  own lifestyle goals.

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MAKING SUCCESSFUL LIFESTYLE CHANGES

• Focus on making goals for the whole family, not
  just the child. This will help the child feel
  supported, and more positive towards making
  lifestyle changes.
• Avoid judgment.

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• Assess the motivation of your child/teen/family
• Success will depend on the degree of readiness
  for change
• Hesitant child/teen
• help motivate towards making small changes
• for some teens the beginning of change will only
  occur when they are ready
• parent(s) will often need help to be patient for
  this step

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• Identify areas of interest in making change.
• Children and teens will often pursue change that
  they suggest themselves.
• For some children/teens may need to offer a set
  of suggested changes from which to choose

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• Be patient and expect that progress will take
  many small steps over time.
• Weight does not turn around quickly but rather
  most commonly takes between 3 and 6 months to
  start

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• Encourage small steps in making lifestyle
  changes.
• provide suggestions in a context of small steps
• e.g. cutting food volume by 30 is too rapid a
  change. 10 reduction in food volume will be
  more effective than a battle to achieve 50 in
  one.
• Most changes needed by children and teens are
  minor in comparison to the adult population, as
  growth is still occurring.

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• Be positive and encouraging
• Children and teens respond far better to positive
  encouragement than criticism.
• Teens in particular may appear very limited in
  their interest or communication. However they
  are often very clear on when they disagree, so we
  take an absence of disagreement as positive.

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• Avoid focusing on the weight as an indicator for
  success.
• Always focus on the positive changes in their
  lifestyle they have made in follow-up, even if
  they have gained weight.
• Weight goal??

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• Involve the child/teen/family in deciding their
  own lifestyle goals.
• Focus on making goals for the whole family, not
  just the child.
• This will help the child feel supported, and more
  positive towards making lifestyle changes.

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• Avoid judgement
• Keep an eye and ear out for any signs of
  development of pre-eating disorder thinking
• Excess efforts to dieting behaviour or rapid
  weight loss
• Excess attention to weight, or weight goals that
  are unreasonable (goal weight)
• Negative self image/body image / body image
  distortion

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Nutrition Related Goals

• Reduce pop / sweetened beverages
• Reduce juice Goal 0-1 per week.
• Limit dairy to 2-4 servings per day
• Limit high calorie foods
• Eat breakfast
• Reduce/eliminate the evening snack
• Teach the 1/41/41/2 rule to plating foods

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Nutrition Related Goals
Eat slowly Learn about hunger and
fullness Write down what you eat and
drink Manage inventory/ Keep mainly healthy
foods in the home/ limit impulsivity
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Nutrition Related Goals

• Avoid eating seconds
• Keep mainly healthy foods in the home. Cut up
  vegetables and fruit, and display them to promote
  healthier snacking.
• Encourage fibre rich foods

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Your stomach is full when it reaches about here
1/2 full. You should feel comfortable, not
STUFFED, and hunger is gone.
Your STOMACH sends a message to your BRAIN when
it is comfortably FULL. But sometimes WE DONT
LISTEN and keep eating! SO, try to STOP eating
when you feel comfortably full.
It take 20 minutes for your stomach to tell your
HYPOTHALAMUS (in your brain) that you are
full. You CANT tell if youre full if you eat
TOO FAST, or under 15-20 minutes. WAIT at least
20 min to decide if you are still hungry.
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Physical Activity
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Activity Reduces Obesity

• Family-based approach diet, activity
• Reduce TV/video games
• Regular activity lifelong

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Physical Activity Prescription
Adequate PA Essential
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New goals Active Living

• Physical activity gt organized exercise
• Feel good activities ? FUN!!
• Enjoying the feeling of movement
• Integrate into daily routine
• Energizing
• Lifelong commitment

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Canadas PA Guide to Healthy Active Living
for Children and Youth

• Children 6-9 years old
• Youth 10-14 years
• http//www.phac-aspc.gc.ca/pau-
  uap/paguide/child_youth/index.html

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Tips to Reduce Sedentary Time

• Immediately ? sedentary time by 30 minutes
• remove TV from childs bedroom
• limit screen time lt 2 hrs/day
• buy screen time minutes with equal physical
  activity minutes
• pre-tape TV shows, fast-forward commercials
• set a good example
• Monthly
• ?15 min/day for reduction of at least 90 min/day

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What are we teaching our kids?

• 70-98 schools sell snacks from machines or
  canteen
• 95 pop/sport drinks 90 bottled water 79
  salty snacks 40 fruit/vegetables
• 2004 - Refreshments Canada 2
• remove carbonated drinks from school vending
  machines
• replace with sport drinks, juice

Vending Machines in Schools
Activity in Schools

• Daily Physical Activity
• High School Phys Ed Elementary School Phys Ed
• Should we keep kids in from playground?
• - for weather
• - for missing work

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The Village Strategies for change?

• As parents/adults
• We model active behaviour
• We model healthy eating
• We learn about hunger and fullness
• We model non-dieting behaviour

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The Village Strategies for change?

• We value physical activity even at
• work
• We limit the tv and screen time
• We walk our kids to school (parents take turns)
• We encourage healthy serving sizes

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SMART Goals

• Specific
• Measurable
• Attainable
• Reviewable
• Time sensitive

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Resources

• Health Canada
• www.healthcanada.gc.ca/foodguide
• http//www.hcsc.gc.ca/hppb/paguide