Obesity Prevention and Education for School Nurses

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.

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.

Obesity Trends

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.

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)

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

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

Obesity in the United States

2009

Trends in Obesity Among Boys

Trends on Obesity Among Girls

 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 (GAO R Childhood Obesity and Physical Activity) The Epidemic of Childhood Overweight and Obesity

Risk Factors for Obesity

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

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

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

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

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

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

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

Consequences of Obesity

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

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

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

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

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)

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.

Economic Burden of Obesity T he Economic Estimates of the impact of obesity are astronomical: Approximately $52 billion was attributed to obesity 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

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

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

Assessing the Overweight/Obese Child

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

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

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

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

Blood Pressure in Children Lower than an Adult – Normal Blood Pressures 4 91/ / / / / / / / / / / / /66 (Selekman, 2006)

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

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 th th th

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 th th th

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)

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 How To Use The BP Tables

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. How To Use The BP Tables

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 th th th

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 th th th

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 th th th

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 th th th

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

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

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

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

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) matologic_diseases/acantho sis_nigrica.html

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 Most commonly found in Hispanics, Native Americans, African Americans, Asian- American/Pacific Islanders (Jones and Ficca, 2007) Acanthosis Nigricans (AN)

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

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

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)

Typical Acanthosis Nigricans of the Neck

Typical Acanthosis Nigricans of the Axillae

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 ChildrenandAdolescents.htm

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

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

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

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

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

Key Components of a Healthy Lifestyle - Education/Counseling 60 minutes of physical activity every day Recommended # of cups of fruits/vegetables per day 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)