1. Obesity Prevention and Education for School Nurses

2. The planning committee & faculty attest that no relevant financial, professional or personal conflict of interest exists, nor was sponsorship of commercial support obtained, in the preparation or presentation of this educational activity.

3. Objectives Define obesity and relate current trends in Arkansas and in the US. Discuss risk factors for childhood obesity. Explain health consequences of obesity. Describe importance of health assessment especially blood pressure monitoring in regards to childhood obesity. Explain the relationship between Acanthosis nigricans and obesity. Describe the process for appropriate height and weight measurement for children. Review pertinent legislation. List resources available for schools and school nurses to combat childhood obesity.

4. Obesity Trends

5. Definition of Obesity Obesity is defined as an increased body weight in relation to height, when compared to some standard of acceptable or desirable weight.

6. Obesity / Overweight in Children Obesity / Overweight in Children Obesity in children / youth refers to age and gender- specific BMI that is equal to or greater than the 95 th percentile of the CDC BMI charts Overweight/at risk for obesity between 85 th – 94 th percentile (IOM, 2007)

7. In the Past Three Decades… Number of overweight: 6-11 year olds tripled Adolescents tripled (Gerberding & Marks, 2004) Overweight adults tripled (>60%)

8. Obesity in Children 16.3% of children and adolescents ages 2 -19 years are obese 11% considered extremely obese 12.4% 2 - 5 year old 17.4% 6-11 year olds 17.6% 12-19 year olds 31.9% are overweight / obese (Ogden, JAMA, 2008)

9. Obesity in the United States http://www.cdc.gov/obesity/data/trends.html

10. 2009

11. Trends in Obesity Among Boys

12. Trends on Obesity Among Girls

14.  9 million children >6 yrs obese (IOM, 2005)  25 million children / adolescents are obese or overweight (NHANES, 2007) » Males 18.2% » Females 16.0 % HHS estimates that 20% of children / youth in the US will be obese by 2010. (GAO-07-260R Childhood Obesity and Physical Activity) http://www.gao.gov/new.items/d07260r.pdf http://www.gao.gov/new.items/d07260r.pdf The Epidemic of Childhood Overweight and Obesity

15. Risk Factors for Obesity

16. Risk Factors for Obesity: Diet Inactivity – High-calorie foods – High-fat foods dense in calories – Soft drinks, candy, desserts high in sugar / calories – Sedentary kids more likely to gain weight – Inactive leisure activities

17. Risk Factors for Obesity: Genetics Risk Factors for Obesity: Genetics Overweight family and child may be genetically predisposed to gain excess weight environment of high-calorie foods physical activity may not be encouraged

18. Heredity… / Genes Heredity… / Genes  80% of children with two overweight parents will become overweight  40% of children with one overweight parent will become overweight  7–9% of children with no overweight parents will become overweight http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.htm

19. Percentage of Overweight Children and Youth Who Become Overweight Adults (National Institute for Health Care Management, Nov 2003)

20. Some eat to cope with problems or deal with emotions; stress or boredom – Parents may have similar tendencies Risk Factors for Obesity: Psychological

21. Environmental / Media Temptation at Every Turn Chips, cookies, and other less healthy food choices are marketed to children via media.

22. Behavioral/Socio-cultural Sedentary lifestyles  Calorie-dense foods  Large portion sizes  Excessive television viewing / video games  low energy expenditure Parent modeling - eating and exercise behaviors

23. Consequences of Obesity

24. Health Consequences: Adult Premature Death 500,000 deaths per year – surpassing tobacco Risk increases with increased weight (USDHHS, 2001)

25. Health Consequence: Children Risk of CVD Hypertension Elevated insulin levels Dyslipidemia – Elevated low density lipoprotein (LDL) – Abnormal triglyceride levels

26. Other Health Consequences Children Sleep apnea Asthma Risk for Kidney problems Gastrointestinal – fatty liver disease – elevated liver enzymes – gallstones and cholecystitis – gastroesophageal reflux – constipation

27. Other Health Consequences Children Endocrine disorders – T2DM – Polycystic Ovary Syndrome – Early sexual maturation Orthopedic disorders Skin conditions AN – seen in:  10% of obese white children  50% of obese black children Skin fungal infections

28. Health Consequences: Psychosocial !!! Children Depression/Anxiety Quality of Life Negative self-esteem/Poor body image Feelings of chronic rejection / Withdrawal from interaction with peers/Behavioral problems Decreased endurance / involvement Social, academic and job discrimination (Deckelbaum and Williams, 2001)

29. Health Consequences for Children – Risk of T2DM Clearly, the growth in the treatment of type 2 diabetes could signal the beginning of a multitude of long-term healthcare needs for many of these children.

30. Economic Burden of Obesity T he Economic Estimates of the impact of obesity are astronomical: 1995 - Approximately $52 billion was attributed to obesity 2003 - This figure had increased to $75 billion (CDC, J. Gerberling, 2005) According to one estimate total health care spending for children who receive a diagnosis of obesity is approximately $750 million a year http://www.medstat.com/pdfs/childhood_obesity.pdf

31. Economic Burden of Obesity Obesity is the No. 1 driver of increasing health care costs in the US today Diabetes contributes to health care disparities in the United States

32. Americans consume 300 more calories/ day than they did 25 years ago & eat less nutritious foods Nutritious foods are…more expensive than calorie- dense, less nutritious foods Americans walk less / drive more -- even for trips of less than one mile Adults often work longer hours & commute farther Parks & recreation spaces are not considered safe or well maintained in many communities Many school lunches do not meet nutrition standards -children engage in less physical activity in school ↑ screen time (TV, video games) contributes to ↓ activity…for children (F as in Fat, 2009) Recap: Rising obesity rates - result of a number of trends in the US

33. Assessing the Overweight/Obese Child

34. Assessment of the Overweight and Obese Child and Adolescent Hypertension Acanthosis Nigricans Nutrition and Physical Activity Child and Family History Height/Weight/BMI

35. Definition of Hypertension Average Systolic blood pressure (SBP) [higher number] and/or diastolic blood pressure (DBP) [lower number] that is ≥ to the 95 th percentile for gender, age and height on 3 or more occasions

36. Definition of Pre-Hypertension Definition of Pre-Hypertension Average SBP or DBP levels that are greater than or equal to the 90 th percentile, but less than the 95 th percentile Adolescents with BP levels greater than or equal to 120/80 mmHg should be considered pre-hypertensive http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

37. Assessing for Hypertension in Children & Adolescents Approximately 9-13% of overweight children have elevated blood pressure Approximately 30% of obese children (BMI >95th percentile) have hypertension

38. Blood Pressure in Children Lower than an Adult – Normal Blood Pressures 4 91/52 6 94/56 7 96/57 8 98/58 9 100/59 10 100/60 11 102/61 12 104/62 13 106/63 14 107/64 15 109/65 16 110/66 17 110/66 (Selekman, 2006)

39. Hypertension Overview New national data added to the childhood BP database Updated BP tables now include the 50 th, 90 th, 95 th, and 99 th percentiles by gender, age and height http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htmhttp://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

40. http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm Blood Pressure Levels for Boys by Age and Height Percentile AgeBP SBP (mmHg) Percentile of Height DBP (mmHg) Percentile of Height Year % tile5 th 10 th 25 th 50 th 75 th 90 th 95 th 5 th 10 th 25 th 50 th 75 th 90 th 95 th 1250 th 10210310410510710810961 626364 90 th 116 11711912012112275 767778 95 th 11912012112312412512679 808182 99 th 127 12813013113213386 8788 8990

41. http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm Blood Pressure Levels for Girls by Age and Height Percentile AgeBP SBP (mmHg) Percentile of Height DBP (mmHg) Percentile of Height Year % tile5 th 10 th 25 th 50 th 75 th 90 th 95 th 5 th 10 th 25 th 50 th 75 th 90 th 95 th 1250 th 1011021041061081091105960616263 64 90 th 115116118120121123 7475 76777879 95 th 119120122123125127 7879808182 83 99 th 1261271291311331341358687888990 91

42. How To Use The BP Tables 1.Use the standard height charts to determine the height percentile 2.Measure & record the child’s SBP and DBP 3.Use correct gender table for SBP and DBP 4.Find child’s age on the left side of the table Follow the age row horizontally across the table to the intersection of the line for the height percentile (vertical column) http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

43. 5.For SBP percentiles in the left columns and for DBP %tiles in the right columns: – Normal BP = < 90 th percentile – Pre-hypertension = BP between the 90 th - 94 th percentile or > 120/80 mmHg in adolescents – Hypertension = BP  95 th percentile on repeated measurement http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm How To Use The BP Tables

44. 6.BP > 90 th percentile should be repeated twice at the same office visit 7.BP > 95 th percentile should be staged : – Stage 1 = the 95 th percentile to the 99 th percentile plus 5 mmHg. – Stage 2 = >99 th percentile plus 5 mmHg. http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm How To Use The BP Tables

45. Blood pressure in children - exercises 1.Boy - 10 y.o. 95 th %tile for height – blood pressure 100/60 Blood pressure is  50 th percentile = normal AgeBP SBP (mmHg) Percentile of Height DBP (mmHg) Percentile of Height Year % tile5 th 10 th 25 th 50 th 75 th 90 th 95 th 5 th 10 th 25 th 50 th 75 th 90 th 95 th 1050 th 979810010210310510658596061 6263 90 th 111112114115117119 73 7475767778 95 th 1151161171191211221237778798081 82 99 th 122123125127128130 8586 88 8990

46. 2. Boy - 12 y.o. 50% %tile for height – blood pressure116/70 Blood pressure is  90 th percentile = normal Blood pressure in children - exercises AgeBP SBP (mmHg) Percentile of Height DBP (mmHg) Percentile of Height Year % tile5 th 10 th 25 th 50 th 75 th 90 th 95 th 5 th 10 th 25 th 50 th 75 th 90 th 95 th 1250 th 1011021041051081091105960616263 64 90 th 115116118119121123 7475 76777879 95 th 119120122123125127 7879808182 83 99 th 1261271291311331341358687888990 91

47. 3. Girl 9 y.o. 90 th %tile for height – blood pressure 118/76 Blood pressure >90 th %tile = prehypertension Blood pressure in children - exercises AgeBP SBP (mmHg) Percentile of Height DBP (mmHg) Percentile of Height Year % tile5 th 10 th 25 th 50 th 75 th 90 th 95 th 5 th 10 th 25 th 50 th 75 th 90 th 95 th 950 th 96979810010110210358 596061 90 th 110 112113114116 72 737475 95 th 114 11511711811912076 777879 99 th 121 123124125127 83 84 858687

48. 4. Girl 16 y.o. 25 th %tile for height – blood pressure 126/80 Blood pressure is >90 th %tile = prehypertension Blood pressure in children - exercises AgeBP SBP (mmHg) Percentile of Height DBP (mmHg) Percentile of Height Year % tile5 th 10 th 25 th 50 th 75 th 90 th 95 th 5 th 10 th 25 th 50 th 75 th 90 th 95 th 1650 th 108 110111112114 64 6566 6768 90 th 12112212312412612712878 798081 82 95 th 12512612712813013113982 838485 86 99 th 13213313413513713813990 919293

49. Classification of Hypertension in Children and Adolescents SBP or DBP Percentile Normal < 90 th percentile Prehypertension 90 th percentile to < 95 th percentile, or if BP exceeds 120/80 even if below the 90 th percentile up to < 95 th percentile Stage 1 hypertension95 th percentile to the 99 th percentile plus 5 mmHg Stage 2 hypertension>99 th percentile plus 5 mmHg http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

50. Frequency of BP Measurement Normal Recheck at next scheduled physical examination Pre-hypertension Recheck in 6 months Stage 1 hypertensionRecheck in 1–2 weeks or sooner if the patient is symptomatic; if BP is persistently elevated on two additional occasions, evaluate or refer to source of care within 1 month Stage 2 hypertensionEvaluate or refer to source of care within 1 week or immediately if the patient is symptomatic Classification of Hypertension in Children and Adolescents

51. Assessing for Hypertension in Children & Adolescents - recap 1.Choose appropriate cuff size 2.Take in upper right arm 3.Cuff should cover approx 2/3 of upper arm 4.Cuff bladder should cover 80–100 % of the arm circumference 5.Adolescent – adult cuff size 6.Large adolescent - extra large cuff 7.Student should sit for 3-5 minutes in a quiet environment before the BP is measured  Refer for BP above the 95 th percentile for either systolic or diastolic

52. Therapeutic Lifestyle Changes Weight reduction - primary therapy for obesity- related hypertension. Prevention of excess weight gain can limit future increases in BP. Dietary modification strongly encouraged in children and adolescents with pre-hypertension and hypertension Physical activity can improve efforts at weight management and m ay prevent future increase in BP Family-based intervention improves success

53. Acanthosis nigricans type III associated with obesity, insulin- resistant states and endocrinopathy Acanthosis nigricans is a disorder that may begin at any age Velvety thickening Gray to brown to black in body creases – Neck, armpits, groin – Darker skinned people have darker lesions (James, et al 2005) http://www.aocd.org/skin/der matologic_diseases/acantho sis_nigrica.html

54. About 90% of children with type 2 have dark shiny patches on the skin, most often found on the back of the neck ("dirty neck") and in axillary creases http://www.childrenwithdiabetes.com http://www.childrenwithdiabetes.com Most commonly found in Hispanics, Native Americans, African Americans, Asian- American/Pacific Islanders (Jones and Ficca, 2007) Acanthosis Nigricans (AN)

55. Most commonly associated with obesity or polycystic ovarian disease in women Can occasionally be found in people who have more serious underlying health problems or taking certain medications Treatment of the underlying medical condition usually resolves the skin lesions

56. What can be done about AN? Acanthosis Nigricans is a marker that signals elevated insulin levels and a risk of developing type 2 diabetes and other conditions in the future Taking immediate action may help delay or prevent the health conditions associated with high insulin levels

57. AN / T2DM = further evaluation The current research does not support that AN will lead to type 2 diabetes (Jones and Ficca, 2007, CDC, 2005) Discuss findings with the student and family Refer the student to seek additional medical advice (Jones and Ficca, 2007)

58. Typical Acanthosis Nigricans of the Neck

59. Typical Acanthosis Nigricans of the Axillae

60. Quick Weight, Activity, Variety, & Excess Survey (WAVE) for Children Evaluate eating practices: quantity quality timing of food intake identify foods/patterns of eating that may lead to excessive calorie intake A means for a quick assessment of diet and activity and may be useful for some clinicians and children http://bms.brown.edu/nutrition/acrobat/wave.pdf http://www.aecom.yu.edu/nutrition/QuickWAVEScreenerfor ChildrenandAdolescents.htm

61. Physical Activity Assessment Assess daily activity levels Include time spent on: exercise and activity sedentary behaviors, such as television, video viewing, and computer use Quick Activity, Variety, & Excess Survey (WAVE) For Kids www.mypyramid.gov

62. MyPyramid.gov The Dietary Guidelines for Americans, 2005, gives science-based advice on food and physical activity choices for health MyPyramid Worksheet Check how you did yesterday and set a goal to aim for tomorrow www.mypyramid.gov

63. Child History  Increased thirst  Snoring  Exercise intolerance  Increased hunger  Acanthosis nigricans  Increased urination  Fatigue  Blurred vision  Weight gain

64. Family History Diabetes risk factors:  Parent or sibling diagnosed with diabetes  Grandparent or aunt/uncle diagnosed with diabetes  Mother diagnosed with gestational diabetes Higher-known risk groups:  African American  Asian American  Pacific Islander  Native American  Hispanic/Latino  < 60 minutes/day of physical play or activity  > 2 hrs of TV/computer/video game use/day

65. Family history of obesity & medical problems Several obesity-related medical conditions are familial Family history predicts type 2 diabetes mellitus or insulin resistance, and the prevalence of childhood diabetes. Cardiovascular disease and cardiovascular disease risk factors -- (hyperlipidemia and hypertension) are also more common when family history is positive. Consider history regarding first- and second-degree relatives (Barlow, 2007) Family History

66. Key Components of a Healthy Lifestyle - Education/Counseling 60 minutes of physical activity every day Recommended # of cups of fruits/vegetables per day http://www.mypyramid.gov/ http://www.mypyramid.gov/ Limit high-fat / high-sugar food/drink Encourage water intake Limit “screen time” to less than 2 hours per day Provide counseling / educate students, families / school staff on the key components of a healthy lifestyle Provide written diabetes prevention materials in appropriate language(s) from the National Diabetes Education Program (NDEP) http://ndep.nih.gov/index.htm http://ndep.nih.gov/index.htm