1. SUPERSIZING Our Children
Childhood Obesity
Welcome to the TOP Star training! The TOP Star training is comprised of six workshops. This is the first workshop entitled Supersizing Our Children in a series of workshops about preventing childhood overweight. This workshop was developed by University of North Carolina Center for Health Promotion and Disease Prevention for the NAP SACC Program. NAPP SACC is an acronym for The Nutrition and Physical Activity Self-Assessment for Child Care. This workshop was revised by the Utah Department of Health in which national data was updated and Utah-specific data included for the purpose of the Top Star program. The set of revised workshops is referred to as the TOP Star training and is approved for professional development credit, 10 hours of Career Ladder Credit in levels 1 health and safety or levels 5-8.
While you listen to this presentation, you may want to boost your metabolism while learning by getting up out of your chair and stretching or doing some strength training exercises such as crunches, leg lifts, bicep curls and/or lunges.
This workshop will introduce you to the issue of obesity and how it is affecting children at young ages, and how you can help. It will be followed by workshops on healthy eating and physical activity.

2. Objectives
Describe the problem of overweight in 2-to 5-year-old children
List the possible consequences of being overweight as a young child
Describe the role of the child care environment and of child care staff in helping to prevent overweight in children
List some ways in which their child care facility can help children eat healthier and get more activity
At the end of this workshop participants will be able to…
Describe the problem of overweight in 2-to 5-year-old children
List the possible consequences of being overweight as a young child
Describe the role of the child care environment and of child care staff in helping to prevent overweight in children
List some ways in which their child care facility can help children eat healthier and get more activity

3. Obesity in America
We are first going to discuss the obesity crisis and how it is affecting the general population.
Obesity is increasing in America, especially among children.
Obesity is caused by many factors, some of which we can’t control, but many of which we can.
Childhood obesity puts kids at an increased risk for health problems later in life.
Child care is an ideal setting to teach children healthy habits and combat childhood obesity.

4. Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2006
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1990
1998
2006
Over the past 20 years there has been a dramatic increase in obesity in the United States. This slide illustrates this trend by mapping the increased prevalence of obesity across each of the states. In 1990, there were no states with obesity prevalence greater than 14%.
In 2006, only four states had a prevalence of obesity less than 20%. Twenty-two states had a prevalence equal to or greater than 25%; two of the states (Mississippi and West Virginia) had a prevalence of obesity equal to or greater than 30%.
No Data <10% %–14% %–19% %–24% %–29% ≥30%
Source: Behavioral Risk Factor Surveillance System, CDC.

5. Obesity Trends* Among U.S. Adults BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
In 2009, only Colorado and the District of Columbia had a prevalence of obesity less than 20%. Utah had a prevalence of obesity of 23.5%.
No Data <10% %–14% %–19% %–24% %–29% ≥30%
Source: Behavioral Risk Factor Surveillance System, CDC

6. Obesity Is Caused by Long-Term Positive Energy Balance
Fat Stores
Energy
Expenditure
Energy Intake
Obesity is caused by ingesting more energy (calories) than is expended (burned) over a long period of time.
Excess calories lead to an accumulation of body fat.

7. Overweight is defined as a BMI of 25-30
Body Mass Index (BMI) is the standard measurement of overweight and obesity
Overweight is defined as a BMI of 25-30
Obesity is defined as a BMI ≥30
~ 31% of American adults meet the criterion for obesity - about 59 million American adults
More than 64% of the US adult population have a BMI ≥ 25
Body Mass Index (BMI) is the standard obesity measurement used by health professionals. BMI is based on a weight-to- height ratio. If a BMI is greater than or equal to 25 an individual is considered overweight and if an individual's BMI is greater than or equal to 30 the individual is considered obese.
Approximately, 59 million American adults (31%) are considered obese and more than 64% of U.S. adults have a BMI greater than or equal to to 25.
SOURCE:

8. More than half of Utah adults are overweight or obese (59.4%)
The percentage of obese adults in Utah has doubled since 1989 (a 136% increase)
Only 23% eat fruits and vegetables at least five times a day
20% report no leisure time physical activity in the past month
Utah's estimated population is over 2.6 million, with roughly 1.8 million adults. Of those adults, more than half are overweight or obese (59.4% BRFSS 2009, age-adjusted). The percentage of obese adults in Utah has doubled since 1989 (a 136% increase).
The primary behaviors causing the obesity epidemic are well known and preventable: physical inactivity and unhealthy diet. Despite this knowledge, only 23% eat fruits and vegetables at least five times a day, and 20% report no leisure time physical activity in the past month.
SOURCE:

9. Only 48% meet physical activity recommendation levels
11% of Utah youth (9th–12th graders) are overweight; another 9% are obese
Only 48% meet physical activity recommendation levels
Only 18% eat fruits and vegetables five or more times a day
Nearly 17% drink at least one non-diet soda each day
18% watch three or more hours of television each day
The problem is not limited to adults.
11% of Utah youth (9th–12th grades) are overweight and another 9% are obese
Only 48% meet physical activity recommendation levels
Only 18% eat fruits and vegetables five or more times a day
Nearly 17% drink at least one non-diet soda each day
18% watch three or more hours of television each day (BRFSS, 2007).
SOURCE:

10. Obesity affects the economy COSTS: -- U.S.: $150 billion per year
-- $1400 per person per year
-- Utah: $393 million per year
Medical costs associated with overweight and obesity may involve direct and indirect costs
Overweight and obesity and their associated health problems have a significant economic impact on the U.S. health care system (USDHHS, 2001). In the U.S., obesity costs $150 billion per year or $1,400 per person per year. In Utah, obesity costs $393 million per year (cdc.gov).
Medical costs associated with overweight and obesity may involve direct and indirect costs (Wolf and Colditz, 1998). Direct medical costs may include preventive, diagnostic, and treatment services related to obesity. Indirect costs relate to morbidity and mortality costs. Morbidity costs are defined as the value of income lost from decreased productivity, restricted activity, absenteeism, and bed days. Mortality costs are the value of future income lost by premature death.
SOURCE:

11. What Factors Affect Obesity?
Biology
Genes
Behaviors
Diet
Physical activity
Screen time
Environments
Social
Physical
There are many reasons why children and adults are overweight. It is a very complicated health problem.
There are factors that aren’t within our control. We cannot change our genes and sometimes we cannot change a health condition that restricts activity or requires medications that cause changes in appetite or weight gain.
Some people use food more efficiently and are more prone to gain weight. During times of famine, this was a genetic advantage, but in today’s society it is not.
There are many more factors that we can control, including what we eat, how active we are and how we interact with each other around food, amount of screentime.
Ask yourself what can I do to prevent obesity in the children under my care. Pause…
Get the kids moving
Encourage staff and families to turn off the television
Offer healthier food options
Be a role model for healthy habits We will go into detail on each of these things throughout the TOP Star workshops.
Focus on what we can change!

12. Why the Increase in Obesity?
Rising obesity rates result from increases in caloric intake and/or decreases in caloric expenditure
The rise in obesity rates in the last decade could be explained by as little as an average net increase of 100 calories per day
FOODS
Calories
2 Oreo cookies
106
4 Hershey’s Kisses
100
8 fl oz Coca-Cola
162
1 Tbsp ranch dressing 90
2 slices white bread
130
SOURCE:
ACTIVITIES
Walking 1 mile 96
Biking 4 miles mph)
102
Jogging 1 mile mph)
120
As little as 100 extra calories per day can cause a person to gain weight. It is important to make sure you compensate with physical activity to create a balance between energy in and energy out.
As you can see from these charts, just adding 2 oreo cookies each day could lead to weight gain unless you also add more physical activity to expend those added calories such as biking 4 10 mph.
SOURCE:
rcise.htm

13. Changes in Caloric Intake from 1970 to 2000
Adults
Men: 2,450 to 2,618 kcal/day (+7% )
Women: 1,542 to 1,877 kcal/day (+22% )
Children
Boys: 2,550 to 2,800 kcal/day (+10%)
Girls: 1,780 to 1,900 kcal/day (+7%)
The total amount of daily calories consumed has increased dramatically for people of all ages and both sexes (men, women, boys and girls) compared to the 1970’s.
Consumption of food away from home increased from 18% to 32% of total calories from to
In 1997, the average American consumed 53 gallons of soft drinks and 17 gallons of fruit juices or drinks
Soft drink consumption +51% since 1980
Fruit juice consumption +40% since 1980
Boys consume 300% more soft drinks than in the 1970s (from 7oz to 22oz per day)
Children’s sugar consumption is twice what is recommended
Children today have diets full of high‐energy dense foods, which are foods relatively high in calories, such as refined grains, added sugars and fat food which lead to obesity.
On the other hand, offering children foods lower in energy density, which are
foods like whole grains, fruits, vegetables, and legumes provide a
protective effect against overweight and obesity. The theory behind
this protective effect is that high‐fiber foods are high in volume, yet
low in calories. This greater volume may help kids feel more full
while consuming fewer calories.
This takes effort in a day and age where processed quick “kid friendly” snacks and meals are readily available to feed children but may not necessarily be the best option.

14. Help, the Environment is
Making US Fat!
According to the U.S. Surgeon General and the Institute of Medicine, policy and environmental changes will be needed to control the childhood obesity epidemic.
We will discuss factors in the environment that make it hard to eat smart and move more.

15. Brainstorm
What factors in the environment make it harder for us to eat smart and move more?
Think about this question for a minute. What factors in the environment make it harder for us to eat smart and move more? PAUSE

16. Urban Sprawl and Time Spent in Cars
A study by Ewing and colleagues used national data from the Behavioral Risk Factor Surveillance System and census data to look at physical activity and urban sprawl
They discovered that the county sprawl index had small but significant associations with minutes walked, obesity, BMI, and hypertension.
Residents of sprawling counties were likely to walk less during leisure time, weigh more, and have greater prevalence of hypertension than residents of compact counties.

17. Street Connectivity and Mixed Use
Walking rates increase when streets easily connect and when residential and business/services are co-located.

18. Poor Access to Recreational Facilities
Physical activity levels are linked to having recreational facilities nearby. Many areas, especially low income, do not have parks, trails, and gyms within walking distance.

19. Lack of Parks and Green Spaces
This holds true for having parks and green spaces close to residences
Absence of places to be active relates to levels of physical activity

20. Density of Fast Food Restaurants
Diet quality is affected by the types of food establishments around us
The more fast food outlets, the more frequently people go to these businesses
We know the challenge to healthy eating that are posed by fast food consumption
The popularity of super sizing has resulted in intake of unnecessary calories
A recent study showed that the availability of fast food and full-service (non-fast food excluding coffee shops, ice cream, soft drink and soda fountain stands, and caterers) restaurants were more available in low and middle income neighborhoods compared to high-income neighborhoods. In addition, neighborhoods that were predominantly Black versus White neighborhoods had higher proportions of fast food among total restaurants.

21. Eating Away from Home Contributes to Portion Distortion
FRENCH FRIES
20 Years Ago
Today
More and more we are eating outside of the house. It’s quick and convenient. How many times do you eat out during the week? Where do you typically eat out?
Many health professionals believe that the increase in our eating out is a big factor in our weight gain.
Restaurant serving sizes tend to be much larger than we would eat at home. Sometimes they can be 3-4 times the amount of food that is recommended!
Over the past 20 years there has been a major change in portion sizes when eating out. For example, French fries used to come in one size now there are multiple sizes and all are bigger. Talk about calorie difference!
Most restaurants use the cheapest ingredients that make the food taste the best. This often involves adding a lot of fat and sugar to their foods. This results in high calorie foods. We probably don’t even realize how many calories we are eating when we eat out!
We tend to drink more high calorie drinks when we eat at restaurants because they use tall glasses and there are often free refills. A 20 ounce regular soda or sweet tea contains about 250 calories!
210 Calories
2.4 ounces
610 Calories
6.9 ounces
Calorie Difference: 400

22. Presence of Convenience Stores and Absence of Grocery Stores
The higher the density of convenience stores and Mom/Pop stores=the poorer nutritional quality of a person’s diet
This holds true for the absence of grocery stores
A recent study showed that an increased availability of chain supermarkets was associated with lower adolescent Body Mass Index (BMI) and overweight and that greater availability of convenience stores was associated with higher BMI and overweight. The association between supermarket availability and weight was larger for African-American students compared to white or Hispanic students and larger for students in households in which the mother worked full time.

23. Price Matters Food prices had been rising from the 60’s-80’s.
Unfortunately, between 1985 and 2000, the nominal price of fresh fruits and vegetables, fish, and dairy products increased by 118%, 77%, and 56%, respectively, whereas the nominal price of sugar and sweets, fats and oils, and carbonated beverages increased at much lower rates—46%, 35%, and 20%, respectively.
No wonder we are stocking our kitchens with less healthy foods!

24. School and Work Poor food choices in cafeteria or vending machines
Minimal PA opportunities, even in schools
Cost: good food does cost more
School or work environments that don’t support or encourage healthy eating or PA
Technology that makes work easier but reduces physical activity
Although the research isn’t abundant in this area, the environment-behavior relationship exists in our work/school settings as well
These are some environmental aspects that have a potential link to obesity
Food choices in cafeteria or school store
Places to be active (quality of outdoor space)
Is there TIME to eat?
Where to store food brought from home?
Work is physically undemanding. We don’t even step next door to speak to a colleague-we send an !

25. Adults control what enters the home!
Availability and accessibility of fruits & veggies and healthy snacks
Family meals, especially for children
Family traditions (walks after dinner, playing with the kids)
What we do at home, before and after work/school and on the weekends has a big effect on our ability to maintain our own weight and those of our children. For instance, what food do we keep in our homes and make readily accessible to our children? Research shows that homes where fruits and vegetables are not only present, but accessible (cutup on the counter or in the refrigerator for children to grab) have children that eat more of them. Also, children who live in homes with more family meals eat more fruits and vegetables and fewer calorie dense foods.
Adults control what enters the home. This is true in child care as well.
Family traditions also play a role. Is it tradition to go outside after dinner or watch TV?
Adults control what enters the home!

26. Home Presence of exercise or play equipment
Outdoor space for child play
Media importance in home (use of TV at meals,video games, etc)
Number and location of TVs
Healthy sleep routines
Research on the home environment is very limited but much interest exists
Some evidence shows the importance of exercise equipment in the home, number and location of TVs, and space for outdoor play has an effect on weight status
We do know more about the media’s influence, especially TV. Watching TV is related to obesity (whether from snacking or inactivity)
Increasing time spent outdoors has a positive impact on a child’s physical activity.
A growing body of evidence suggests healthy sleep routines are protective against obesity (10 ½ hours per night for young children)

27. Childhood Obesity
Now we are going to talk about the overweight problem and how it relates to children.

28. Background Current child obesity epidemic
As of 2005, 56% of children aged 3-6 yrs enrolled in child care centers
Child care setting is ideal for promoting early development of health behaviors
A lot of children attend child care these days, the majority of whom are in child care centers. They spend just as much time here as they do at home! This is why the child care environment is so important.
In 2005, 56% of children ages 3 to 6 were enrolled in child care center. What a great opportunity to make an impact!

29. BMI = compared to growth charts
BMI that falls between the th-95th percentile = overweight
BMI at or above the 95th percentile = obese
Body Mass Index is also used to measure if children are overweight or obese. A child’s BMI is determined from their height and weight measurements, just like adults. This number is then plotted on a growth chart based on the child’s age and sex to determine their BMI percentile
If a child’s BMI falls between the 85th -95th percentile the child is considered overweight, and if a child’s BMI is at or above the 95th percentile they are classified as obese.

30. Obesity in children
Currently, 26% of U.S. children aged 2-5 are classified as either overweight or obese.
This graph shows a 3-fold increase in the obesity rate for 2-to 5-year-olds since the early ’70s.
Some groups, for example Mexican-American 2-to 5-year-old boys are disproportionately affected.
Every year more and more preschool children are considered overweight.
Preschool children who are overweight are nearly five times more likely to be overweight as young adults.
The longer a child is overweight, the more likely she/he will be an obese adult at risk for many chronic conditions and health problems.
Starting prevention programs early is a good idea.

31. Overweight and Obesity Utah First Graders
Utah Department of Health, Bureau of Health Promotion, collected heights and weights on elementary school age children in 2002, 2006, 2008, and This graph shows the prevalence of overweight and obesity among first grade boys and girls in 2002 and More boys than girls were at an unhealthy weight in both sample years. First grade girls showed an increase in unhealthy weight from 2002 (13.4%) to 2008 (18.3%). Obesity among first grade girls increased by 50% from 2002 to Clearly, obesity prevention needs to start in the early childhood years, as too many children (nearly one in five) are already at an unhealthy weight by the time they are in first grade.
Source: Height Weight Measurement Project, Utah Department of Health

32. Early Childhood Overweight and Obesity Utah WIC Program, 2009
As of 2009, approximately 1 in 5 Utah WIC preschool-aged children were at an unhealthy weight. The rate of overweight among WIC kids ages 2-4 has increased from 11.9% to 12.3% from , while obesity increased from 5.5% to 8.8%.
Source: Pediatric Nutrition Surveillance System, Utah WIC Program, 2009

33. Early Childhood Overweight and Obesity by Race/Ethnicity, 2009
The WIC data show a disparity between race/ethnic groups for prevalence of unhealthy weight among children ages 2 through 4. The rate is much higher for Hispanic (67% higher), American Indian/Alaskan Native (146% higher), and Asian/Pacific Islander children (88% higher).
Source: Pediatric Nutrition Surveillance System, Utah WIC Program, 2009

34. Should We Be Concerned?
Overweight is now the most common nutritional disease of children
Preschool children who are overweight are nearly 5x more likely to be overweight as young adults
Obesity is a risk factor for many chronic conditions and health problems
By now, you probably realize that we should be concerned about the weight of children in child care.
Overweight is very common. In fact, in some communities it is so common that the parents of very overweight children do not see the problem. So many of the children they know also are overweight that they are used to it.
The longer a child is overweight, the more likely she/he will be an obese adult at risk for many chronic conditions and health problems.

35. What are the health risks for overweight and obese children?
Brainstorm
What are the health risks for overweight and obese children?
Think for a minute, what health risks are associated with childhood overweight?
We will discuss some.

36. Health Risks of Obesity
Heart Disease
 Total cholesterol
 Serum triglycerides
 Blood pressure
Breathing problems
Type 2 diabetes
Musculoskeletal problems
Weight discrimination
Some children are just big kids: they have bigger bones, are taller, and are heavier than other children. But most of the children we are talking about today are at an unhealthy weight, meaning they are carrying too much weight for their body size and thus are at risk for certain diseases later in life.
60 percent of overweight children 5-10 years of age already have at least one risk factor for heart disease (high cholesterol, high triglycerides, or high blood pressure)
Many overweight children have difficulty keeping up with lighter peers and they get tired more easily. Children with asthma who are also overweight may have increased symptoms, and in extremely overweight children breathing problems can be very severe.
Type 2 diabetes used to be called adult onset diabetes, but now it is being diagnosed in children as young as 9.
Problems with joints, like the knees, hips and spine, usually don’t show up until adolescence or adulthood, but carrying extra weight over many years takes a toll on the body. Our bones were not intended to carry and support too much extra weight.
Children who are overweight sometimes suffer from weight discrimination. Their peers, and sometimes adults, make assumptions about them because of their weight (lazy, no self-control). Children can be cruel and may ridicule or exclude overweight classmates. This can lead to depression and low self-concept.
Other health risks could be:
Depressive symptoms
Low self-concept
Poor body image
Fatty liver
More like to be obese as adults

37. Contributors to Child Obesity
Food choices
Physical activity
Obese parents
Parents with poor health behaviors
Eating patterns
Parenting style
Low birth weight
Excessive weight gain in pregnancy
Formula feeding
Adults control most of these contributors to child obesity!!!
Food Choices - diets higher in calories (including fats and simple sugars) and lower in fruits and vegetables are linked with overweight
Physical Activity vs. Sedentary Activity - less physical activity and more time spent participating in activities such as watching TV result in less energy expenditure
Parental Obesity - children of obese parents are more likely to be overweight themselves. There is an inherited component to childhood overweight that makes it easier for some children to become overweight than others. There are a number of single gene mutations ("genetic alterations") that are capable of causing severe childhood overweight, though these are rare. Even children with genetic risk for overweight can still become overweight only if they consume more calories than they use. Parental obesity may also reflect a family environment that promotes excess eating and insufficient activity.
Eating Patterns - skipping meals or failure to maintain a regular eating schedule can result in increased intake when food is eaten.
Parenting Style - some researchers believe that excess parental control over children's eating might lead to poor self regulation of kids’ energy intake.
Diabetes During Pregnancy - overweight and type 2 diabetes occur with greater frequency in the offspring of diabetic mothers (who are also more likely to be obese)
Low Birth Weight - Low birth weight (<2500 g) has been shown to be a risk factor for overweight in several epidemiological studies.
Excessive Weight Gain During Pregnancy - Several studies have shown that excessive maternal weight gain during pregnancy is associated with increased birth weight and overweight later in life.
Formula Feeding - Breastfeeding is recommended over formula feeding. Although the exact mechanism is unknown, several long-term studies suggest that breastfeeding may prevent excess weight gain as children grow.
Parental Eating and Physical Activity Habits - Parents with poor nutritional habits and who lead sedentary lifestyles role model these behaviors for their children, thereby creating an "obesegenic" home environment.
Demographic Factors- Certain demographic factors are associated with an increased risk of being overweight in childhood. For example, there is evidence that African-American and Hispanic children 6 to 11 years old are more likely to be overweight than are non-Hispanic white children of the same age. Asian and Pacific Islander children of the same age were slightly less likely to be overweight

38. Focus on what we can change!
What Can We Do?
Factors within our control
Nutrition (eating)
Physical activity
Feeding interactions
Support breastfeeding mothers and children
Focus on the things we can change:
The types and amount of foods and beverages we offer children
The opportunities children have for physical activity
The amount of screen time children have
The messages we give children and families about food, eating and physical activity
Support breastfeeding mothers and children
Focus on what we can change!

39. YOU CAN MAKE A DIFFERENCE!
Child care providers are advocates for healthy children!!
You can make a difference! Child care providers are great role models for children. Be an advocate of a healthy lifestyle and for healthy children.

40. Brainstorm What is the role of child care?
What can you do to prevent obesity in preschoolers?
Take a minute to think about the following questions.
What is the role of child care?
What can you do to prevent obesity in preschoolers?

41. Making Changes in the Child Care Environment
ACTIVITY
Making Changes in the Child Care Environment
Pull out the handout that says “Improving YOUR Center’s Nutrition and Physical Activity Environment.” Fill this out individually or as a group to help you begin thinking of ways that you can make changes. The handout is attached on the following slide. Some suggestions are:
Discuss healthy habits, not body type
Choose healthy food to serve, but allow children to choose what to eat
Serve a variety of foods with more F/V, whole grains
Bake, broil, roast or grill meats instead of frying them.
Limit use of high calorie, high fat and high sugar sauces and spreads.
Limit juice- (water available at all time)
Be active as a group
Encourage free play
Provide time outdoors
Role model healthy habits
Restrict screen time
Support breastfeeding mothers and children
Make things fun!!

43. Summary Convenience has made things TOO easy
Obesity is more than just a personal decision!!
More than 1 in 4 preschoolers are overweight or obese
Child care providers can help keep kids healthy
Too many children are overweight and at risk for serious health problems.
Unhealthy food choices and physical inactivity contribute to unhealthy weight.
Together we can make a difference!