1. I DARE YOU Daniel E. Hale, MD Professor of Pediatrics Chief, Division of Pediatric Endocrinology and Diabetes University of Texas Health Science Center at San Antonio

3. Five things to share with families when you see an overweight child (or an overweight parent).

4. I DARE YOU 1. Turn off the television 2. Children walk (run, bike, hike, swim) 3. Water/low fat milk are the only beverages at home 4. Fast food is a 1 time per week treat 5. Fruits and vegetables are the only snacks After the dare, Morton was never again seen in school

5. How many hours of TV does the typical American child watch? A. 1 hour B. 2 hours C. 3 hours D. 4 hours

6. Turn Off the Television - 1 Children spend ~4 hours a day watching television, DVDs and videos. 68% of 8- to 18-year-olds have a TV in their bedroom; 54% have a DVD/VCR player, 37% have cable/satellite TV, and 20% have premium channels. In 63% of households, the TV is "usually" on during meals. Roberts DF, Foehr UG, Rideout V. Generation M: media in the lives of 8-18 year- olds. Kaiser Family Foundation. March 2005

7. Turn Off the Television - 2 In 53% of households of 7th- to 12th- graders, there are no rules about TV watching. In 51% of households, the TV is on "most" of the time. Kids with a TV in their bedroom spend an ~1.5 hours more per day watching TV than kids without a TV in the bedroom.

8. Turn Off the Television - 3 TV viewing is replacing preferred activities in a childhood (like playing, reading, doing homework or chores). Kids who spend more time watching TV (both with and without parent and siblings present) spend less time interacting with family members. Bickham DS, Rich M. Is television viewing associated with social isolation? Roles of exposure time, viewing context, and violent content. Arch Pediatr Adolesc Med. 160:387-92, 2006. Vandewater EA, Bickham DS, Lee JH. Time well spent? Relating television use to children's free-time activities. Pediatrics 117:e181-91, 2006.

9. Turn Off the Television - 4 Excessive TV viewing contributes to poor grades, sleep problems, behavior problems, obesity, and risky behavior. Children' s programming may not teach what parents say they want their children to learn; shows are filled with stereotypes, violent solutions to problems, and mean behavior. On average, children see ~22,000 TV commercials each year. This includes many ads for unhealthy snack foods and drinks. American Academy of Pediatrics. Television—what children see and learn. Available at: http://www.aap.org

10. Turn Off the Television - 5 Being awake with the TV on for >2hr/day is a risk factor for being overweight at ages 3 and 4 ½ years. Weekend TV viewing in early childhood affects body mass index in adulthood. The best predictors for being overweight among 3- to 7-year-olds, are physical activity and TV viewing. TV was a bigger factor than diet. Inactivity and TV became stronger predictors as the children aged.  Lumeng JC, Rahnama S, Appugliese D, Kaciroti N, Bradley RH. Television exposure and overweight risk in preschoolers. Arch Pediatr Adolesc Med. 2006 Apr;160(4):417-22.  Viner RM, Cole TJ. Television viewing in early childhood predicts adult body mass index. J Pediatr. 2005 Oct;147(4):429-35.  Jago R, Baranowski T, Baranowski JC, Thompson D, Greaves KA. BMI from 3-6 y of age is predicted by TV viewing and physical activity, not diet. Int J Obes (Lond). 2005 Jun;29(6):557- 64.

11. Turn Off the Television - 6 Children who watch TV are more likely to be inactive and tend to snack while watching TV. Two-thirds of the 20,000 TV ads an average child sees each year are for food; most are for high-sugar foods. All television shows replace physical activity. While watching TV, the metabolic rate often goes even lower than during rest. Klesges RC, Shelton ML, Klesges LM. Effects of television on metabolic rate: potential implications for childhood obesity. Pediatrics 91:281-6, 1991. McGinnis JM, Gootman JA, Kraak VI, eds. Food marketing to children and youth: threat or opportunity? Washington, D.C.: National Academy Press; 2006.

12. Turn Off the Television - 7 The food and beverage industry targets children with their television marketing, which may include commercials, product placement, and character licensing. Most of the products pushed on kids are high in total calories, sugars, salt, and fat, and low in nutrients. Recent studies have reported success in reducing excess weight gain in preadolescents by restricting TV viewing. Caballero B. Obesity prevention in children: opportunities and challenges. Int J Obes Relat Metab Disord 28 Suppl 3:S90-5, 2004.

13. No Apologies Necessary (AAP Position Statement) Too much television can negatively affect early brain development. This is especially true at younger ages, when learning to talk and play with others is so important. The AAP does not recommend television for children age 2 or younger. For older children, the Academy recommends no more than 1 to 2 hours per day of educational, nonviolent programs

14. Marketing to Children

15. Tips For Parents (AAP) 1.Set limits 1 hour, 2 hours, only after supper and homework are completed 2.Plan your child's viewing Make TV a “conscious” choice (no passive TV watching) 3.Watch TV with your child TV in public, not private, space 4.Find the right message Does the program reflect your views/values/behaviors 5.Help your child resist commercials Ask your child about the “message” (You will be surprised) http://www.aap.org/family/tv1.htm

16. Tips For Parents (AAP) 6. Look for quality children's videos The Coalition for Quality Children's Media http://www.cqcm.org 7.Give other options Coloring books, family games, a walk 8.Set a good example Turn on the TV with a purpose 9.Express your views If you do not approve of something, talk about it with your children! 10. Get more information http://www.aap.org/family/tv1.htm

17. Children Walk

18. What are the US Surgeon General’s recommendations for physical activity for adults? A.1 hour per day, 6 days per week B.1 hour per day, 3 days per week C.20 minutes per day, 6 days per week D.40 minutes per day, 7 days per week

19. Walk - 1 During the 7 days pre-survey, 77% of children aged 9-13 participated in free-time physical activity, and 39% participated in organized physical activity. 36% of high school students had participated in > 60 minutes per day of physical activity on ≥5 of the 7 days preceding the survey. Of these, 64% of high school students participated in sufficient vigorous physical activity, and 27% participated in sufficient moderate physical activity. Participation in physical activity declines as children get older. Youth Behavioral Risk Survey, 2005

20. Walk - 2 Type of ActivityGirlsBoys >60 min/day(1)27.8%43.8% Daily PE (2)29.0%37.1% i.e., the major source of physical activity for most children is at school (1) Any activity that increased heart rate and made them breathe hard some of the time for at least 60 minutes per day on 5 or more of the 7 days preceding the survey (2) Attended physical education classes 5 days in an average week when they were in school Youth Behavioral Risk Survey, 2005

21. Walk - 3 Over half (54%) of high school students (72% of 9 grade students but only 39% of 12 grade students) attended PE in 2005. In 2005, 45% of 9 graders but only 22% of 12 graders attended daily PE. Among the 54% of students who attended PE, 84% actually exercised or played sports for 20 minutes or longer during an average class. High school students attending PE classes daily decreased from 42% in 1991 to 25% in 1995, (stable since then).

22. Walk - 4 Physical education “time” does not equal moderate to vigorous physical activity –The “HEALTHY” experience Mandating the time “by law” does not result in change –The California experience

23. Walk - 5 Physical activity –Assessing fitness –Differing measures (by country, state) Analysis of data from around the world, including the US. –Approximate rate of decline in physical fitness is about 0.5% per year since ~1980. Pediatric Fitness: Secular Trends and Geographic Variability; Editor(s): Tomlinson, G.R. Olds, T.S. 2007 Karger AG, Basel.

24. Walk - 6 Parents estimate that their children get 11.5 hours of physical activity per week. Children and youth average 6.5 hours per week (most of which is not moderate to vigorous physical activity).

25. Walk- 7 The American Heart Association recommends that children and adolescents participate in at least 60 minutes of moderate to vigorous physical activity every day. The Centers for Disease Control and Prevention recommend that children and youth accumulate at least 60 minutes daily of moderate to vigorous physical activity in a variety of enjoyable individual and group activities. Pediatrics 117, 1834-1842, 2006

26. MVPA Moderate activity+ 3.0 to 6.0 METs* (3.5 to 7 kcal/min) Walking at a moderate or brisk pace of 3 to 4.5 mph on a level surface inside or outside, such as Walking to class, work, or the store; Walking for pleasure; Walking the dog; or Walking as a break from work. Walking downstairs or down a hill Racewalking—less than 5 mph Using crutches Hiking Roller skating or in-line skating at a leisurely pace Vigorous activity+ > 6.0 METs* (more than 7 kcal/min) Racewalking and aerobic walking—5 mph or faster Jogging or running Wheeling your wheelchair Walking and climbing briskly up a hill Backpacking Mountain climbing, rock climbing, rapelling Roller skating or in-line skating at a brisk pace http://www.cdc.gov/nccdphp/dnpa/physical/terms/index.htm

27. Walk - 8 Simple Suggestions –Walk zones (1 block, ¼ mile) Resources –Google (anything) –http://www.kidshealth.org –http://www.mayoclinic.com/health/fitness/ –http://bam.gov (CDC) –http://www.verbnow.com

28. Water/low fat milk are the only beverages at home and school

29. Beverages - 1 A Math Lesson 3500 calories = 1 pound An imbalance of 100 calories per day = 36,500 calories in 1 year 100 calories = ~8oz of most sugared beverages 36,500 calories = 10.4 lbs So forget the math and just remember that an extra 100 calories per day caloric excess each day for a year is 10 lbs (i.e., small changes can make a difference)

30. Beverages - 2 Average 12-19 yrs of age drinks  Boys -28 oz of soda / day 5% > 60 oz / day  Girls - 20 oz / day 5% > 36 oz / day

31. Beverages - 3  28 oz = 325 cal  3500 cal = 1 lb  325 cal/day = 119,233 cal/yr  325 cal/day ~ 32.5 lbs/yr

32. Beverages - 4 The “Big Gulp” and a grab bag of chips (99¢ all summer) 62 oz = 720 cal Chips = 280 cal 1000 cal/day = 2 lbs/wk “School’s out” = 20 lbs/10 weeks

33. Beverages - 5 “Texas Soda Wars” Susan Combs

34. Beverages - 6 Benefit to schools –$54 million (~$6/case) –Sports equipment –Scholarship –Special programs School budget from State = $14.4 bil (2002) Total spending on education was 40.7 bil

35. Beverages - 7  55 sodas per child per year at school  55 x 240 calories = 13,200  13, 200 / 3,500 = 3.77 pounds  The average weight gain for: –A 7 year old girl is ~4 lbs/year –A 12 year old girl is ~10 lbs/year –A 16 year old girl is ~6 lbs/yr

36. Beverages - 8 Benefit to Beverage company –162 million (~$18/case) –“Branding for life” –“Captive audience” –Positive public relations –Advertising at a profit for 180 days/yr

37. Beverages - 9 It’s the economy, stupid! Profit  $6.24 per case for soda  $1.80 per case for milk/water

38. Beverages - 10 Girls ages 9-10 at start Followed for 10 years (NHLBI Growth and Health Study) 2,371 girls 3 day food diaries Anthropomorphic measures http://www.nhlbi.nih.gov/resources/deca/descriptions/nghs.htm

39. Beverages - 11 Age (years)9.512.515.518.6 Regular soda (gms)36217274377 Diet soda (gms)22507182 Milk (gms)352320290242 Fruit juice (gms)110104125129 Fruit drinks (gms)78958087 377 gms = ~12 ounces of soda = 140 calories = 14 lbs per year

40. Guess which color is the “healthy stuff”?

41. Limit Use of Fast Foods (1X/week)

42. Fast Foods - 1 Pop Quiz A Big Mac, Supersized Fries and a 16 oz shake contain enough calories to: 1.Be an excellent lunch choice for you 2.Be the total daily nutrient intake of a health adult female 3.Be the total daily nutrient intake for a marathoner 4.Be the ideal lunch for a hungry 10 year old

43. Fast Foods - 2 Pop Quiz Answer: This is the entire daily caloric need for the typical adult female or 80% of the needs for the adult male. Answer: To burn off this many calories, one needs to walk ~4 hours http://www.primusweb.com/fitnesspartner/ jumpsite/calculat.htm

44. Fast Foods - 3 Meals eaten “out” (1996)30% % of weekly food budget45% % children eating out/day40% Children’s fast food $21 bil

45. Fast Foods - 4 Portion size (1977-1996) Calories Desserts+55 Burgers+96 Mexican food+133 JAMA 2003; 289:450-453

46. Fast Foods - 5 High energy (calorically dense) High total and saturated fat High cholesterol High sodium Low Vitamin A & C Low folic acid Low calcium Low fiber J Am Diet Assoc 2003; 103: 1332-1338

47. Fast Foods - 6 Pediatrics 2004; 113:112-118 National survey 4-19 year olds Eating OutEating at home Calories22362049 Total fat (gm)8475 Total CHO (gm)303277 Fiber (gm)13.214.3 Milk (gm)236302 Fruits/Vegs (gm)103148

48. Fast Foods - 7 SupersizingCaloriesFat (gm) Hamburger28010 Quarter pounder & cheese54029 Small fries23010 Supersize fries61029 Soft drink (12 oz)1500 Soft drink (supersize)4100 660 calories vs 1660 calories (250% increase)

49. Fast Foods - 8 Longitudinal study, girls, age 8 &12 at start –Fast food ≥ 2 / week vs ≤1 / week –More rapid increase in BMI over time Cross sectional, both sexes, ages 4 -16 –Overweight – more servings of food and beverages away for home –this correlated with the % body fat

50. Fast Foods - 9 Tips for parents The best “combo” is fast food with activity (e.g., post hike) Avoid supersizes, doubles, etc (>500 calories beware) Brainstorm about easy food to prepare at home (and use the internet) Moderation in all things/appropriate portion sizes Start early, with yourself (parents are role models) Offer choices, but limit them (milk or water) Toys come from the toy store, not the restaurant Use the websites of fast food restaurants – find those things that < 500 calories

51. Snack foods – whole fruit and vegetables

52. Fruit and Vegetables - 1 < 15% of elementary students eat the recommended 5 or more servings of fruits and vegetables every day. Average fruit and vegetable intake among 6-11 year olds is only 3.5 servings a day. >50% of all elementary students eat no fruit on any given day and 3/ 10 students eat <1 serving of vegetables a day. 1/4 of all vegetables eaten by elementary students are French fries, a high-fat, low nutrient vegetable option.

53. Fruits and Vegetables - 2 2 year olds116 5 year olds107 Primary care provider office (well-child check-ups), white middle class families 7 day diet diaries (careful instructions) Calculations based on USDA guidelines Dennison, et al. J Am Coll Nutr 17:371-378 (1998)

54. Fruit and Vegetables - 3 Most children eat less than 1 serving of fruits, fruit juices or vegetables per day and this does not vary much by age

55. Energy density (Calories per gram) High-energy-dense foods: 4-9 calories per gram (e.g., cookies, crackers, butter, bacon) Medium-energy-dense foods: 1.5-4 calories per gram (e.g., bagels, dried fruits, hummus, part- skim mozzarella) Low-energy-dense foods: 0.0-1.5 calories per gram (e.g., most fresh fruits and vegetables, fat-free yogurt, broth-based soups) Fruit and Vegetable - 4

56. Feeling full is more likely to make a person stop eating than the total calories consumed. –20 participants ate as much as they wanted from food offered to them over 5 days. –The diet alternated from low-energy-dense to high- energy-dense foods. –The participants felt full on the low-energy-density diet after eating just over half the calories (1570 kcal) they consumed before feeling full on the high-energy-density diet (3000 kcal). * Duncan KH, Bacon JA, Weinsier RL. The effects of high and low energy density diets on satiety, energy intake, and eating time of obese and nonobese subjects. Am J Clin Nutr 1983;37:763-7. Fruit and Vegetable - 5

57. Fruits and Vegetables - 6 Short-term studies: Low-energy-dense foods promoted feeling full, reduced hunger, and provided fewer calories. Long-term studies: Low-energy-dense foods promoted moderate weight loss. Studies lasting longer than 6 months: Weight loss was 3X greater for people who ate foods of low energy density than for those who simply ate low-fat foods. Yao M, Roberts SB. Dietary energy density and weight regulation. Nutr Rev 2001;59:247-58.

58. Fruits and Vegetables - 7 Whole fruit is more filling (satiating). Whole fruit contains fiber, and juice is fiber-free. *Haber GB, Heaton KW, Murphy D, Burroughs LF. Depletion and disruption of dietary fibre. Effects on satiety, plasma-glucose, and serum insulin. Lancet 1977;2:679-88. *Bolton RP, Heaton KW, Burroughs LF. The role of dietary fiber in satiety, glucose, and insulin: studies with fruit and fruit juice. Am J Clin Nutr 1981;34:211-17.

59. Review* of Dietary Intervention Studies Many studies have found that significant weight loss can occur when advice to increase the intake of fruits and vegetables is coupled with advice to reduce energy intake. *Rolls BJ, Ello-Martin JA, Tohill BC. What can intervention studies tell us about the relationship between fruit and vegetable consumption and weight management? Nutr Reviews 2004;62:1-17.

60. I DARE YOU (for the child over 2) 1. Limit screen time to <2 hrs/day 2. At least 1 hr of MVPA per day 3. Water/low fat milk are beverages of choice 4. Fast food is a 1 time per week treat 5. Fruit and vegetables are the only snacks

61. Beginning the Discussion Aspirational (Teens) –What do you want to be doing 20 years from now? Generational (Parents/grandparents) –Breaking the chain Emotional (Parents of younger children) –Making memories for your children

62. Your roles Be a role model (your behaviors are noticed) Pay attention to activity levels, sedentary behaviors and eating habits in children (and advocate for healthy alternatives) Provide information on healthy eating/ physical activity to children and parents when the opportunity presents itself Promote sustainable behaviors in your community

63. Think about …… For thousands of years, ]Physical activity was required for survival ]Entertainment involved interaction with other humans ]Starvation was the enemy most feared.

64. For thousands of years,  Physical activity was required for survival.  Entertainment involved interaction with other humans.  Starvation was the enemy most feared. In this modern age,  Physical activity has been replaced by technology.  Most entertainment involves interaction with a television or a computer.  Abundance is now the plague that will rob children of their eyes and limbs. Think About This

65. If you are concerned about your child’s weight (or your own weight), then here are 5 things that you can begin to change. 1.Turn off the television (& computers and play stations) No more than 2 hours/day for kids > 2 years old 2.Children walk (run, bike, hike, swim) At least 1 hour of vigorous physical activity 3. No sugary beverages (sodas, sports drinks, fruit juices) Water/low fat milk are the only beverages at home 4.Fast food is a treat 1 time per week (beware of any “meal” >500 calories) 5. Healthy snacks Fruits and vegetables (beware of everything else)

66. Here’s How Why do you want to change? What do you want to change? What are you doing now? How are you going to get your family involved? Who is going to support you (and keep you honest)?