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Childhood Obesity and the Modern Lifestyle: Implications for Future Generations.

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Presentation on theme: "Childhood Obesity and the Modern Lifestyle: Implications for Future Generations."— Presentation transcript:

1 Childhood Obesity and the Modern Lifestyle: Implications for Future Generations

2 “I think we’re looking at a first generation of children who may live less long than their parents as a result of the consequences of overweight and type 2 diabetes.” Francine Ratner Kaufman, MD Head, Division of Endocrinology & Metabolism Children’s Hospital Los Angeles

3 Definition of Obesity A chronic preventable disease Obesity is defined as excess body fat (not simply excess weight)

4 Definition of Obesity BMI - Body Mass Index = weight/(height)(height) Adult definitions: –Overweight - BMI 25-29.9 –Obesity - BMI > 30 Children definitions: –Overweight - BMI for age >95th %ile –At risk for overweight - BMI for age > 85th %ile


6 Calculating Body Mass Index (BMI) BMI (English): [ weight (lb) / height (in) / height (in) ] x 703 BMI (metric): [ weight (kg) / height (cm) / height (cm) ] x 10,000 BMI Conversion Tables: Web Calculator: Palm Calculator and Growth Chart: BMI Calculator Wheel: $5 REGIONAL HEALTH EDUCATION BMI = 28 BMI Does Not Measure Body Fat







13 Percentage of Overweight Children and Youth who Become Obese Adults Preventive Medicine 1993; Vol. 22:pp. 167-177 Arch Pediatr Adolesc Med Vol. 158 May 2004 pp. 449-452 S Gee, Kaiser Permanente



16 Obesity Associated Morbidity in Childhood Hypertension (9X risk compared to non-obese) Dyslipidemia Gall bladder disease Polycystic ovarian syndrome Fatty liver Early menarche Pediatrics 1998; 102(3)

17 Obesity Associated Morbidity in Childhood Type 2 diabetes of childhood/IGT or Pre- diabetes Independent risk factor for early CV disease Peer teasing/poor self esteem/depression/ negative self image and eating disorders Obstructive sleep apnea – in about 7% of obese children Higher prevalence of moderate to severe asthma in overweight children and adolescents Ortho—slipped capital femoral epiphysis, Blount’s disease, osteoarthritis of the knees, weight stress on growth plates of lower extremities (pain & decreased ROM)


19 Metabolic Syndrome among Overweight Children and Adolescents Metabolic Syndrome (1)  Criteria: TG>=110 mg/dL, HDL-C =90%, FBS>=110 mg/dL, BP>= 90% (3 of 5 criteria needed)  Prevalence = 28.7% among overweight adolescents. The prevalence of metabolic syndrome increased with the severity of overweight and reached 50% in severely overweight children. (2) 1. Arch Pediatr Adolesc Med Vol. 157, Aug 2003 pp. 821-827 2. N Engl J Med Vol. 350, June 2004 pp. 2362-2374

20 Epidemiology of Overweight in Kids in General U.S. Population

21 Preliminary data collected between 2000-2004 from the Nutrition Education Needs Assessment Survey (NENAS) conducted in the public schools every ten years shows an overweight problem among youth and teenagers: ‘At risk’ for overweight OverweightTotal 4 th graders15.7%20.2%35.9% High school students 17.8%18.9%36.7%

22 Recent research studies suggest that Hawaii has a significant problem with childhood obesity. A cross-sectional study of more than 20,000 children aged 2-4 years participating in the Hawaii WIC program in 1997-98, found that the prevalence of overweight in all ethnic groups was above the expected 5% (Baruffi et al., 2004).

23 Ethnic Variation in Prevalence of Overweight Among WIC Children Multivariate analysis showed that ethnicity had a strong independent association with BMI and overweight. Children 2-4 years, Hawaii WIC program, 1997-98% overweight Asian9.0 Black7.3 White8.5 Filipino12.4 Hawaiian11.3 Hispanic10.1 Samoan27.0 Other11.9 Total11.4


25 Assessment of Height and Weight (BMI) Among Public School Students Entering Kindergarten, 2003-2004 By the State Department of Health Methods Retrospective record review of school health records: 12,682 children were enrolled in kindergarten in the DOE for the 2002-2003 school year. 12,240 Student Health Records were available for review. 10,676 records had complete data for age, sex, weight and height. 145 records with miscoded entries or implausible values for height and weight were omitted based on CDC criteria. 986 pre-kindergarten students with completed records were omitted from this study.

26 Results of kindergarten assessment: A large proportion of Hawaii 4 & 5 year olds enter public schools with weight problems: 14 % Overweight 15% ‘At-risk’ for overweight 29% Combined ‘at–risk’ and overweight





31 Adult Weight Surveillance Methodology The Behavioral Risk Factor Surveillance System, a population based telephone survey conducted in Hawaii and throughout the U.S. reports rates of overweight and obesity among adults. The BRFSS is an annual telephone survey of adults 18 years and older, which assesses the risk for chronic diseases, injuries and other health risk factors. In the BRFSS, BMI is calculated based on self-reports of height and weight status.


33 Why is childhood obesity increasing? Many theories: –Decrease in physical activity with less opportunities for recreational activities for children and young adults/Increasingly sedentary life style –Increase in availability and consumption of dense caloric foods –Lower incidence of breastfeeding –In utero effects of diabetes

34 SupersizingSupersizing “Old Days”Hamburger 280 kcal Double Whopper with Cheese 1120 kcal

35 Increased Calories Classic Coke 8 fluid oz 100 kcal 1950 Extreme Gulp 52 fluid oz 2002 630 kcal

36 MVPA* > 20 min in PE class 1991- 34.2% 1997- 21.7% Less Physical Activity for Kids *Activities that caused sweating and hard breathing for at least 20 minutes on 3 or more of the 7 days preceding the survey.

37 TV and Obesity Multiple U.S. and international studies Increased TV viewing time associated with increased weight Causes? –Increased sedentary activity –Increased calorie consumption snacking while viewing effect of commercials on food selection

38 Childhood Overweight Family Risk Factors  One obese parent (3X increase)  Two obese parents (13X increase)  Early puberty Pediatric Overweight: A Review of the Literature The Center for Weight and Health College of Natural Resources University of California, Berkeley

39 Overeating and Psychological Distress “Youths who overeat may have or be at risk for serious psychological distress, including deficits to self-esteem, compromised mood, and suicide risk. Overeating may be a tangible behavior that signals the need for intervention.” Ackard et al, Pediatrics 2003;111:67-74

40 Depression and Obesity “Depressed adolescents are at increased risk for the development and persistence of obesity during adolescence.” Goodman and Whitaker, Pediatrics 2002;109:497- 504 “Depression during childhood is positively associated with BMI during adulthood.” Pine et al, Pediatrics 2001;107:1049-56

41 Lower Childhood SES and Insulin Resistance “Adverse social circumstances in childhood, as well as adulthood, are strongly and independently associated with increased risk of insulin resistance and other metabolic risk factors.” Lawlor et al, BMJ 2002;325:805

42 “Growing up in such conditions could teach the child of parents with lower SES that the world is a hostile, depressing, and alienating place, and the child could also learn that smoking and consumption of larger amounts of alcohol and food help reduce the resulting distress.” Redford Williams, JAMA 1998;21:1746

43 What the Medical Community Can Do Implement BMI screening and waist circumference screening for all patients. Promote the use of national guidelines and standard protocols by health care providers for the management of obesity. Assess co-morbidities. Raise the issues of overweight or obesity, or inappropriate weight gain even when overweight is not present.




47 Who needs medical intervention?

48 Sarah E. Barlow and William H. Dietz, Obesity Evaluation and Treatment: Expert Committee Recommendations, Pediatrics 1998 102: e29

49 Treatment Goals Attain skills for a lifetime of weight management –self monitoring of eating, physical activity and weight –social and emotional support –continued contact with the treatment team Realistic Weight Goal (may differ from that initially expressed by the teen or parents) For many, allow to grow into one’s weight (i.e. weight maintenance)

50 Treatment Principles Health promotion is the primary goal (NOT dieting) Family, not the child or teen, is identified as the patient

51 Recommended Weight Goals Weight loss approx. 1 pound/month Weight goal: BMI< 85% Sarah E. Barlow and William H. Dietz, Obesity Evaluation and Treatment: Expert Committee Recommendations, Pediatrics 1998 102: e29

52 Summary Points for Management of Childhood Overweight Obesity may be genetic or endocrine Be aware of its complications in children Instilling healthy eating habits is better than restricting diet Sustainable lifestyle activities should be encouraged Psychosocial problems are important consequences of overweight or obesity Behavioral treatments should be individually designed All treatments must be acceptable to the family Pediatrics July 2004;114:217–223

53  Calculate and plot BMI once a year in all children and adolescents.  Encourage and support breastfeeding.  Encourage parents to promote healthy eating patterns.  Routinely promote physical activity.  Recommend limitation and television and video time to a maximum of 2 hours per day.  Recognize and monitor changes in obesity- associated risk factors for adult chronic disease. Prevention of Pediatric Overweight and Obesity American Academy of Pediatrics Policy Statement Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

54 Individual – Pub. Ed. Social Norms – Pub. Ed. Social Professional – Teaching & Prof. Ed. Policy/Structure/Environment - Schools Policy/Structure/Environment - Communities Policy/Structure/Environment – County/State Public Health Response: Social-Ecological Model (CDC)

55 Policy, Structure, Environment Communities Promoting walkable communities Introducing workplace wellness initiatives and incentives

56 Developing teams at worksites and communities throughout the state Supporting the Kaua‘i Great Weigh Out that included nutrition education classes, incentives and team physical activity events


58 Social Norms Public Education Media: TV, Radio, Theaters, Print Partnerships & Special Events Website:

59 Policy, Structure, Environment Schools Coordinating school health across components Supporting healthy food options during school hours Promoting access to physical activity and physical education Supporting health education and PE requirements and infrastructure

60 Examples of food policy changes to reduce childhood obesity Eliminate access to “junk food” in elementary schools during the daytime (e.g. vending machines, canteens, fund-raising booths, etc.) Require that where vending machines, etc are present in middle and high school, that fruits and vegetables be offered in these settings Require closed campus during lunch in elementary and middle schools Prohibit schools from using junk food coupons as a reward for students Prohibit schools from displaying advertisements promoting junk foods, including on vending machines Require school food service managers be well trained Knehans, A.W.; J OSMA 95(8),2002

61 Schools and Physical Activity One additional hour of physical education in first grade compared to kindergarten reduces BMI among girls who were overweight or at risk for overweight in kindergarten. Am J Public Health Vol. 94 September 2004, pp. 1501-1506

62 Social Professional Teaching and Professional Education Public health workforce development in core competencies Grade K to 12 teacher trainings in health education and physical education Summer graduate courses for teachers

63 Some school based interventions have demonstrated improvements in physical activity, TV viewing, food choices and BMI. Advantages include: Addresses all children not just overweight. Captive audience. Lower costs when compared to clinical programs and possibly cost-effective*. Disadvantages include: In some cases less effective compared to clinical programs with regard to behavior change and BMI improvement. Lack of parent involvement and behavioral therapy. School Based Weight Management Interventions * Obesity Research. 2003;11:1313-1324

64 Barriers to Care Dysfunctional family situation Medical model – individual patient vs. family focus Environmental obstacles: lack of transpor- tation, limited access to healthy foods Specific cultural issues, including beliefs about diabetes Eating and mood disorders, life stresses, low self-esteem Lack of appropriate role models Lack of cultural sensitivity among health care providers

65 Goals: 1. Increase access to healthy foods. 2.Increase opportunities for physical activity for Head Start children, parents, staff and communities. 3.Mobilize the communities on health promotion through local partnerships and local capacity building. 4. Promotion of healthy lifestyles through advocacy for policy change & dissemination of promising practices.

66 Summary Good News/Bad News Weight loss/ weight maintenance and effective treatment of type 2 diabetes in childhood and adolescence IS possible Childhood obesity/type 2 diabetes has taken priority in many research venues …and in local and national health programs …emphasis on prevention is gaining momentum It’s not easy Drop out rates are high Magnitude of type 2 diabetes for all children is expected to increase There are multiple barriers to effective treatment/ prevention Hospital costs for childhood obesity-related diseases have tripled in the past 20 years ($35M to $127M in 1999)* Hospitalizations for obesity tripled, for diabetes doubled and for sleep apnea increased 5X in the past 20 years* *Pediatrics, May 2002

67 Childhood overweight and Type 2 diabetes are emergent public health concerns Magnitude of type 2 diabetes in all children is expected to increase Recognize children at risk of becoming overweight and obese early Recognize, treat and prevent adverse childhood experiences Become involved in developing and implementing school- and community-based programs to promote self-esteem, coping and behavior skills, and improved dietary and physical activity for all children and their families

68 Implications for Future Research (1)Hawaii provides a unique opportunity to do more research about BMI measurement issues among Pacific Islanders and Asians; (2)Providers need to acknowledge that cultural norms about body size exist among many Asian and Pacific peoples; (3) We do not know enough about what different populations in Hawaii think of “obesity” (a western medical term) or body size relative to health; (4)We need to find culturally appropriate ways to work with all diverse groups regarding achieving a healthy weight.

69 MAHALO TO Chiyome L. Fukino, MD, Director of Health Kelly Moore, MD, FAAP, IHS Division of Diabetes Treatment and Prevention Margaret West, MPA, Dept. Native Hawaiian Health, UH JABSOM




73 Study population for kindergarten assessment N=9,804 eligible and complete records. Age ranged from 48 to 71 months (4-6 years). The mean age was 57 months. EpiInfo 2000 NutStat was used to calculate percentiles for BMI (body mass index), height for age and weight for height, which uses the 2000 CDC reference population.

74 Percent obese among adults 20 years or older by Community areas, Hawaii BRFSS combined year data set, 2000-2003 (age-adjusted)

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