1. Obesity and Opportunities for Education Sandeep K. Gupta MD Associate Professor of Clinical Pediatrics, Division of Pediatric Gastroenterology Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202 sgupta@iupui.edu No conflicts of interest with this presentation

2. Introduction Obesity has taken epidemic proportions Development of effective prevention and intervention models is a public health priority Containment requires multi-pronged strategy due to complex etiological factors and multitude of stake-holders Stakeholders include: families, schools, universities, health care-providers and payors, health department, local government, employer, media, food industry etc

3. Obesity Education Education in obesity can be an effective tool Education in obesity is actually a required tool Includes education of various components –Patient/family –Health-care provider – physician, nurse practitioner, nurse, resdients, students –Society/Environment: schools, food industry, payors, marketing/media, policy-makers

4. Longjohn MM. Ped Annals 2004;33:55-63

5. Patient Education Includes –Understanding the condition and underlying reasons –Recognizing the detriments to health –Knowledge of interventions

6. Patient Education: Nutrition Popular drinks are caloric-dense: Soda 12 oz =120 calories Juice 16 oz = 220 calories Big Mac590 calories Large Fries540 calories Large Drink410 calories Adds up to 1540 calories !!! (and this is not Super-size!)

7. (Newman C. National Geographic 2004;Aug:46-61)

8. Health-Care Provider Education Includes –Understanding the condition and etiology –Recognizing co-morbidities –Knowledge of interventions From Basics to Esoteric ?easiest piece of puzzle

9. Body Mass Index (BMI) BMI = kg/m 2 BMI adult:20-25 kg/m 2 Normal 25-29 kg/m 2 Overweight > 30 kg/m 2 Obese Obese I30-34.9 Obese II35-39.9 Extreme obese > 40 Super obese > 50 Mega obese >70 Pediatric BMI interpretation

10. Complications Liver Disease: -Non-alcoholic fatty liver disease (NAFLD) -Non-alcoholic steatohepatitis (NASH) Metabolic Syndrome Endocrine issues –Type 2 diabetes –Lipid dysmetabolism

12. Society Education Schools Health and Education Departments Social Services – WIC program Food Industry Payors Media/Marketing

13. A picture is worth a thousand words…….

14. (Skinner JD, et al. Am Dietetic Association 2004) 37 29

15. (Newman C. National Geographic 2004;Aug:46-61)

16. Some Examples McDonalds Garden salad 100 calories Ranch Dressing (1 pkt) 170 calories!!! Cheesecake Factory Carrot Cake 1560 calories/1 slice Fat-free or sugar-free does not equate calorie-free

19. 1998 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2006 (*BMI 30, or about 30 lbs. overweight for 54 person) 2006 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%

20. The obesity epidemic has been linked to unprecedented outbreak of what disease among young people? A. Psoriasis B. Type 2 Diabetes C. Type 3 Diabetes D. Mad Cow Disease

21. The obesity epidemic has been linked to unprecedented outbreak of what disease among young people? A. Psoriasis B. Type 2 Diabetes C. Type 3 Diabetes D. Mad Cow Disease

22. How can we effectively deliver the message? Education at all levels

23. Health-Care Providers Educate the health-care provider Enpower to evaluate and educate the family Bullet messages: e.g be able to identify the problem – do BMI Lectures, seminars, audio-conferences, mailings

25. Immediate Response

26. Conclusions from CPOA The overall impression of CPOA was extremely positive and prompted changes in healthcare practice by nearly two-thirds of respondents Helped narrow the knowledge gap of healthcare providers in Indiana local communities Audio-conferences with distribution of presentation slides for subsequent use by attendees can be an effective tool to prompt awareness and action by healthcare providers in rural communities

27. Patients/Families Illustrate problem objectively – e.g. plot BMI Provide programs/support services Take every opportunity to educate

28. Health Promotions Learn and Live Well

29. CTK Program – School Based Fitness and nutrition program to teach practical ways to implement long-term healthy lifestyle changes 14 hour program; flexible to meet a school schedule 3 components to each lesson; can be split through the day –Nutrition –Behavior management –Physical Activity All lessons tied to state educational standards in Health, Physical Education, Science, Reading, Writing and Math Optional grading assignments available for each lesson as is option to use these assignments as homework if teacher wishes

30. Preliminary Results/Lessons Complete data available on 29/162 high school and 63/126 elementary school students The elementary group, but not high school group, as a whole decreased their BMI – highlights import of early intervention Ability to meld into regular curriculum a huge plus Cost of program: about $20/participant

31. CTK Program - Family 10 week long program – one hour session each week for 10 weeks Evening sessions – parent and child attend Addresses Nutrition Education, Behavior Management, and Physical Activity

32. Web-based Education SAIL (Stay Active In Life) program Web-based program for patients and families General and Disease-specific components http://rileychildrenshospital.com/parents-and- patients/programs-and-services/sail/index.jsp

33. Health Promotions Learn and Live Well

34. Fight the Fat Educates and gives adults the tools to live active and healthy lifestyles Along with teaching Nutrition and Fitness, it places emphasis on Behavior Management such as Stress Management, Goal setting, Diet Diaries, Exercise Logs, Journaling and Overcoming barriers 1 hour per week for 8 sessions

35. Payors Various Agencies lobbying as services are not being reimbursed Care involves Physicians, Nurses, Dietitians, Social Workers, Physical Therapists, Exercise Physiologists, Others Lack of specific ICD-9 codes and nuances e.g. ICD-9 783.1 (excessive weight gain) may pay better than 278.0 (obesity) Effective educational tool would include associated co- morbidities and health-care costs

36. Schools Many opportunities but not primary responsibility Effective tools include the Local Wellness Policy (Public Law 108-265)

37. Legislator/Policy Makers Vending machines in schools Juices by WIC program Mandating physical education in schools Effective tools: beverage intake slide, decreasing physical education slide, CDC slides

38. Food Industry, Media Very important to bringing these on board Effective tools: serving sizes slide, hidden calories (dressings), minimizing children advertisement blitzes

39. So, where does the Buck stop? Ultimately patient/family is responsible, but… We need to provide a conducive environment We have come a long way – from thinking that there is a medical reason to most obesity (leptin deficiency)…..

40. Nature 1994

41. So, where does the Buck stop? Ultimately patient/family will be responsible We need to provide a conducive environment We have come a long way – from thinking that there is a medical reason to most obesity (leptin deficiency) to recognizing that it is a societal and environmental problem that can not be solved during a 30 minute visit to the physician but rather by addressing the various components