Children and Weight

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					Children and Weight
       Dorothy Smith RD
 Nutrition, Family & Consumer
         Science Advisor
    University of California
                   Objectives
   Participant will be able to:
    • Define childhood overweight
    • Identify consequences of childhood overweight
    • State factors related to childhood overweight
    • Identify possible approaches to resolving
      overweight epidemic
    • State first rule of intervention
    • State benefits of creating coalitions to resolve
      overweight issue
  The Epidemic of the Century
• “Not preventing obesity is responsible for 1,000 deaths per day.”
    – C. Everett Koop, M.D., former U.S. Surgeon General


• “The epidemics of diabetes and obesity are clearly escalating in the United
  States…If we continue on this course for the next decade, the public health
  implications in terms of both disease and health care costs are staggering.”
    – Jeffrey P. Koplan, M.D., former CDC Director


• “More people die in the United States of too much food than of too little,
  and the habits that lead to this epidemic become ingrained at an early
  age… It is time to elevate this issue to the top of the public health agenda
  alongside cancer, heart disease and other leading killers of Americans
  today. “
    – Dan Glickman, Secretary of Agriculture
America’s Weight & Health Problem




• Obesity is skyrocketing in every age group, in
  every race, in both genders, and in every
  state of the union.
 Contributing to about 300,000 deaths per

  year, obesity is only exceeded by smoking as
  a cause of death.
               Definitions

   Body Mass Index (BMI) measures
    heaviness of the body
    • Weight (kg) / height (m2)
    • Body heaviness correlates well, but
      not perfectly, with body fat
    • BMI does not address body
      composition
 Obesity Classification
      for Adults
       Overweight:              BMI > 25 kg/m2
       Obesity:                 BMI > 30 kg/m2
                                           Obesity
BMI                                         Class
25.0 – 29.9            Overweight
30.0 – 34.9            Obesity                   I
35.0 – 39.9            Obesity                   II
> 40.0                 Extreme Obesity             III
  NHLBI Guidelines, June 1998
        What Is BMI?

• Body mass index (BMI)  =
     weight (kg)/height (m)2

• BMI is an effective screening
 tool; it is not a diagnostic tool

• For children, BMI is age and
 gender specific, so BMI-for-age is
 the measure used
         Correlation of BMI With
             Total Body Fat
100
 90
 80
 70
 60
 50
 40
 30
 20
 10
  0
       0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160

                                                   Adipose Tissue (kg)
Zumoff, B et al. J Clin Endocrinol Metab. 1990; 70:929-931.
  How is Overweight/Obesity
    Measured in Children?
BMI is calculated the same as for adults, but
overweight/obesity is determined by gender specific CDC
BMI-for-age Charts.
   Example
   Let’s take a look at BMI for a boy as he grows, yet
   remains at the 95th percentile BMI-for-age.

         Age          BMI       Percentile
         2 years         19.3         95th
         4 years         17.8         95th
         9 years         21.0         95th
        13 years         25.1         95th
           Interpreting BMI for
        Children and Adolescents
Underweight                     BMI-for-age < 5th
                                percentile
At risk of                      BMI-for-age > 85th
overweight                      percentile
Overweight                      BMI-for-age > 95th
                                percentile
CDC Growth Charts with BMI-for-age Percentiles are available at:
http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm
      Caveat and Advantages of
                       BMI-for-Age
• BMI is an effective screening tool; it is not a diagnostic tool

• BMI in children and adolescents compares well to laboratory
  measures of body fat.

• BMI is related to health risks

          Correlates with clinical risk factors for cardiovascular disease
               (including hyperlipidemia, elevated insulin, and high blood
               pressure)

          BMI-for-age during adolescence is related to lipid levels and
               high blood pressure in middle age
CDC Growth Charts 2000


Centers for Disease Control and Prevention
  National Center for Chronic Disease Prevention
               and Health Promotion
      Division of Nutrition and Physical Activity
        Maternal and Child Nutrition Branch
Advantages of BMI-for-Age
 Provides a reference for
 adolescents that was not
 previously available
 Consistent with adult
 standards so can be used
 continuously from 2 years of
 age to adulthood
 Tracks childhood overweight
 into adulthood
National Data
                     Prevalence of Adult Obesity

                25

                20
Percent Obese




                15

                10

                 5

                 0
                                 92

                                         93

                                                94

                                                       95

                                                              96

                                                                   97

                                                                        98

                                                                             99
                 90

                          91




                                                                                   00
                        19

                               19

                                       19

                                              19

                                                     19

                                                            19

                                                                   19

                                                                        19

                                                                             19
                19




                                                                                  20
                                                          Year

                     Behavioral Risk Factor Surveillance System
Obesity Trends Among U.S. Adults
      between 1985 and 2000

    Source of the data:
   The data shown in these maps were
    collected through CDC’s Behavioral
    Risk Factor Surveillance System
    (BRFSS). Each year, state health
    departments use standard procedures
    to collect data through a series of
    monthly telephone interviews with U.S.
    adults
               Obesity* Trends Among U.S. Adults
                          BRFSS, 1985
                      (*BMI  30, or ~ 30 lbs overweight for 5’4” person)




        No Data        <10%           10%-14%            15-19%         20%
Source: BRFSS, CDC.
            Obesity Trends* Among U.S. Adults
                       BRFSS, 1991
                           (*BMI  30, or ~ 30 lbs overweight for 5’4” woman)




No Data            <10%             10%-14%                15-19%        20%
   Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
                  Obesity Trends* Among U.S. Adults
                             BRFSS, 1995
                           (*BMI  30, or ~ 30 lbs overweight for 5’4” woman)




No Data            <10%             10%-14%                15-19%        20%
   Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
                  Obesity Trends* Among U.S. Adults
                             BRFSS, 2000
                           (*BMI  30, or ~ 30 lbs overweight for 5’4” woman)




No Data            <10%             10%-14%                15-19%        20%
   Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
           Obesity Trends* Among U.S. Adults
              BRFSS, 1991, 1995 and 2000
                     (*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
                    1991                                                     1995




                                             2000




No Data           <10%           10%-14%            15-19%            20%

Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
  Prevalence of Overweight and
  Obesity U.S. Adults, Age 20-74
             Years*
                          NHANES II                NHANES III            NHANES
                           1976-80                   1988-94               1999
                          n = 1,446                 n=11,207             n=14,468

% Overweight
or Obese                    47                          56                          61
(BMI > 25.0)

 % Overweight 32                                     33                              34
 (BMI 25.0-29.9)

 % Obese                    15                          23                          27
 (BMI > 30.0)


    *Age-adjusted by the direct method to the year 2000 U.S. Bureau of the Census
    estimates using the age groups 20-34, 35-44, 45-54, 55-64, and 65-74 years.
  What is the overweight
trend among children and
   youth in the United
          States?
             Trends in Pediatric
                Overweight
25
                                                      F   6-11 years

                                                      J   12-19 years
20



15
                                                J
                                                F
                                        F
                                        J
10

                       F
               J
 5     J               J
       F       F


 0
     1963-70 1971-74 1976-80 1981-87 1988-94   1999
      Prevalence of Overweight*
        Among U.S. Children
          and Adolescents




 *Gender- and age-specific BMI > the 95th percentile
 Source: Centers for Disease Control and Prevention
  (CDC), National Center for Health Statistics (NCHS)
     Changes in the Prevalence of Obesity
           (BMI > 95th Percentile)
        Among U.S. Female Children and Adolescents
15
                                       NHES I (1963-65 and 1966-70)


10                                     NHANES I (1971-74)


                                       NHANES II (1976-80)


5                                      NHANES III (1988-91)




0
         6-11y           12-17y
  Overweight children and
adolescents 6-17 years of age
 16
 14
 12
 10
                                                             6-11 year old girls
 8
                                                             12-17 year old girls
 6                                                           6-11 year old boys
 4                                                           12-17 year old boys
 2
 0
        1963-      1971-       1976-      1988-
        1970       1974        1980       1991


      Centers for Disease Control and Prevention, National Center for Health Statistics
Behavioral Risk Factor
 Surveillance System
       (BRFSS)
    Youth in grades 9 through 12
   16% of students were at risk for
    becoming overweight
   9.9% of students were overweight




     Youth Risk Behavioral Surveillance System, 1999
                        NHANES III
   25% of school-aged children are
    either overweight or at risk of
    becoming overweight
   11% overweight
   14% at risk for becoming overweight




      National Health and Nutrition Examination Survey III
  Prevalence of Overweight in
Low-income Children 0-12 Years

   16
   14
   12
   10                                                National
    8                                                California
    6                                                Solano County
    4
    2
    0
        1991 1992 1993 1994 1995 1996 1997 1998


  Pediatric Nutrition Surveillance System (PedNSS)
 Percent of Overweight among
Low-income children by Ethnicity

            16
            14
            12
   Percent  10
             8
  Overweight 6
             4                                                         California
             2
             0                                                         United States
                     White




                                        Hispanic




                                                               Asian
                                                   Native Am
                             Black




                                     Ethnicity

1999 Pediatric Nutrition Surveillance System (PedNSS)
                                    Rates of Childhood Obesity
                                     Persisting into Adulthood

                              100
Percent overwt in adulthood




                                                                          80
                                                             70
                              75


                              50                   41

                              25       14

                               0
                                    6 months      7 yrs   10-13 yrs   Adolescence
                                               Age of Obese Child
         Tracking of
         overweight
   Overweight 6 year old children
    as compared to their non-
    overweight peers have 10 times
    the risk of becoming overweight
    adults

   Overweight 10 year old children
    have 28 times the risk of
    becoming overweight adults
 Tracking BMI-for-Age from Birth to
18 Years with Percent of Overweight
 Children who Are Obese at Age 251




 Whitaker et al. NEJM:
 1997;337:869-873
               Obesity is one of the biggest public health
                         challenges of our time
             Almost two-thirds (61%) of                                   In 1991, only 4 states had obesity rates of 15% or
              American adults are seriously                                 greater and no states had rates of 20% or greater. By
              overweight or obese.5 Obesity                                 2000,
              rates have increased by 60%                                   49 states had rates of at least 15%, and 22 states had
              over the past decade.6                                        obesity rates of at least 20%.6

             Obesity rates in children have                                 Prevalence of obesity** among U.S. adults,
              doubled over the last two                                                 BRFSS 1991-20009
              decades — one in seven (5
              million)7 children are obese.8



Percentage of young people
     who are obese8
              15


              12


              9
    percent




              6


              3                                                                     **Approximately 30 pounds overweight.
               *Data for 1966-70 are based on adolescents ages 12-17.
              0
                   1963-65, 1971-74   1976-80 1988-94   1999
                   1966-70*
                         6-11 year olds       12-19 year olds
  Defining
 Overweight
and Obesity:
What are the
  Issues?
                        Six Leading Diseases
                               DEATHS                 CHANGE IN
                                IN 1998              MORTALITY
                              (THOUSAN               RATE, 1980 -                LEADING RISK
  DISEASE                         DS)                   1998                       FACTORS
                                                                              High Cholesterol,
  Coronary Heart                                                              Hypertension, Smoking,
                                    460                     -47%
  Disease                                                                     Obesity, Physical
                                                                              Inactivity
                                                                              High Cholesterol,
  Stroke                            158                     -38%              Hypertension, Smoking,
                                                                              Obesity

  Lung Cancer                       155                     +6%               Smoking

  Chronic
  Obstructive
                                    113                    +34%               Smoking
  Pulmonary
  Disease
  Diabetes                           65                    +35%               Obesity
                                                                              Inadequate Diet,
  Colon Cancer                       57                     -24%              Physical Inactivity
  All Causes                       2,337                    -19%
SOURCE: American Public Health Association, Changes in mortality rates are based on age-adjusted data.
             Consequences of
              Adult Obesity
•Type 2 diabetes           • Sleep Apnea
•Cardiovascular Disease    • Osteoarthritis
   –Hyperlipidemia         • Cancers
   –Hypertension               –Endometrium
   –Respiratory                –Breast
•Coronary artery disease       –Prostate
•Stroke                        –Colon
•Gall bladder disease      • Psychosocial
Degree of risk
  increases
with degree of
 overweight
  Obesity and Hypertension
            Risk
                                                      Men          Women

           40


           30


           20


           10


             0
                     <21          21-22          23-24          25-26      27-28   29-30   31+


                                                        BMI Levels
Canadian Guidelines for Healthy Weights. Cat No. H39-134/1989E; 1988:69.
                 Obesity and Diabetes
                         Risk
        100

          80

          60

          40

          20

             0
                        <20              20-25         25-30    30-35   35-40   >40


                                                       BMI Levels
Knowler WC, et al. Am J Epidemiol. 1981;113:144-156.
                           Weight Gain and
                            Diabetes Risk
                                          Weight Change Since Age 21

                                                   <5 kg   5-10 kg       11+ kg

               25
                                                                                              21.1
               20

               15

               10                                                      9.1
                                           6.3                                          5.3
                 5                                              3.5
                                    2.5                                           2.1
                              1                            1
                 0
                                  <22                          22-23                    24+
                                           Body Mass Index at Age 21
Chan JM, et al. Diabetes Care. 1994; 17:960-969.
                                   DIABETES
• Approximately 80% of people with type 2 diabetes are obese at
  the time of diagnosis1
• Average of 21,025 deaths annually attributable to diabetes in
  California (1994-1997)2
• About 300,000 California hospital discharges listed diabetes as
  one of the top 10 diagnoses each year (1992). These
  hospitalizations represented 2.4 million days, or 6,575 years, of
  hospital stay.3
• 1997 medical expenditures for people with diabetes totaled
  $77.7 billion in U.S. Diabetes Care, Vol. 21, o. 2, February
  1998: pp.296-309.


SOURCES: 1. Chronic Disease and Epidemiology and Control 2 nd Ed. 2. California Diabetes Control Program; The
Burden of Diabetes in California, January 2000 3. California Diabetes Control Program; Why Should We Be
Concerned About Diabetes?
           Unhealthy eating and inactivity cause
          disability and can reduce quality of life
                                                                        Number of Americans Affected by Diet- and
    Diabetes: Obesity’s Twin Epidemic
                                                                        Inactivity-Related Diseases
   Diabetes rates have been rising along with obesity rates.
                                                                        Seriously Overweight/Obese7   113,360,000
    Between 1990 and 2000, diabetes rates rose 50%. 6
                                                                        High Blood Pressure7          50,000,000
   Type 2 diabetes can no longer be called ―adult onset‖
                                                                        Diabetes10                    15,700,000
    diabetes because of rising rates in children. In a study
    conducted in Cincinnati, the incidence of type 2 diabetes           Coronary Heart Disease7       12,600,000
    in adolescents increased ten-fold between 1982 and
                                                                        Osteoporosis11                10,000,000
    1994.15
                                                                        Cancer12                       8,900,000
   Between 50% and 80% of diabetes cases are associated
                                                                        Stroke7                        4,600,000
    with unhealthy eating patterns and sedentary lifestyles. 1,16

   Through physical activity and healthy eating, the onset of          Stroke is a leading cause of serious long-
    type 2 diabetes was reduced by 58% in at-risk individuals.           term disability.7
    (In comparison, the diabetes drug metformin reduced the
    onset of type 2 diabetes by 31%.)17                                 2.2 million Americans have disabilities
                                                                         resulting from high blood pressure.13
   Diabetes is a leading cause of serious disabilities
    such as blindness and amputation. Each year, 12,000
                                                                        Most hip fractures are caused by
    to 24,000 people with diabetes become blind, more than
                                                                         osteoporosis.11,14 Of people over age 50
    100,000 receive treatment for kidney failure, and about
                                                                         who fracture a hip, 24% die within one year
    86,000 undergo diabetes-related lower-extremity
                                                                         and 25% require long-term care.11 (A
    amputations.10
                                                                         broken hip is the second leading cause of
                                                                         admission to nursing homes.)
  Mortality Rate Associated
         with Obesity
Obese individuals have a 50 to
 100% increased risk of death
 from all causes, compared with
 normal-weight individuals.

Most of the increased risk is
 due to cardiovascular causes.
      Unhealthy eating and physical inactivity
          cause 1/3 of premature deaths
   Two-thirds of premature            Only 12% of Americans eat a
    deaths are caused by poor           healthy diet consistent with
    nutrition, physical inactivity      federal nutrition
    and tobacco. HHS estimates          recommendations.3 The
    that unhealthy eating and           typical American diet is too
    inactivity cause about 1,200        high in saturated fat, salt, and
    deaths every day. That’s 5          refined sugar and too low in
    times more than the number          fruits, vegetables, whole
    of people killed by guns, HIV,      grains, calcium, and fiber.
    and drug use combined.1
                                       Diet and inactivity are cross-
   60% of Americans are at risk        cutting risk factors,
    for health problems related to      contributing significantly to
    lack of physical activity.          four out of the six leading
    Regular physical activity helps     causes of death.
    to prevent heart disease,
    colon cancer, obesity,
    diabetes, and high blood
    pressure.2
Leading Causes of Death 4
(Diet and inactivity are leading          Leading Contributors to
risk factors for causes of death
                                          Premature Death 1
shown in red.)

 1. Heart Disease               709,894
                                          Diet and Physical
 2. Cancer                      551,833
                                          Inactivity      310,000-580,000
 3. Stroke                      166,028
 4. Chronic Lower Respiratory   123,550
                                          Tobacco260,000-470,000
 Diseases                                 Alcohol 70,000-110,000
 5. Accidents                    93,592   Microbial Agents       90,000
 6. Diabetes                     68,662   Toxic Agents    60,000-110,000
 7. Pneumonia and Influenza      67,024   Firearms        35,000
 8. Alzheimer’s Disease          49,044   Sexual Behavior        30,000
 9. Nephritis                    37,672   Motor Vehicles 25,000
 10. Septicemia                  31,613   Drug Use        20,000
 11. Suicide                     28,332
 12. Chronic Liver               26,219
        Disease/Cirrhosis
 13. High Blood Pressure         17,964
 14. Pneumonitis                 16,659
 15. Homicide                    16,137
    Economic Impact of Obesity
   About 9.4 percent of the national health care expenditures in the
    United States are directly related to obesity and physical
    inactivity.
 The health-care costs of diabetes in the U.S. are staggering—an
  estimated $105 billion in 1992 according to one study. California’s
  share of this cost in 1992 was approximately $12 billion from all
  sources.
Annual Direct and Indirect Costs Attributable
      to Obesity in the United States
         (Billions of 1995 Dollars)
Disease              Direct Costs           Indirect Costs
Type 2 Diabetes      $ 32.4                 $ 30.7
Coronary Heart
                     $   7.0                $   NA
Dz
Hypertension         $   3.2                $   NA
Gallbladder          $   2.6                $   0.1
Breast Cancer        $   0.8                $   1.5
Endometrial
                     $   0.3                $   0.5
Cancer
Colon Cancer         $   1.0                $   1.8
Osteoarthritis       $   4.3                $ 12.9
        Sub-Total $ 51.6                    $ 47.5
Wolf and Colditz, Ob Res 1998;6:97 Grand Total $ 99.1
                 “Sick Care” versus Health Care
        Factors influencing gain in life expectancy:                                   National spending for population-based
                       1900-199924                                                                  prevention25




                                                                                         Population-based Prevention ($26 billion)
                                                Curative Medicine: 5 years




      Public Health and Preventive Measures: 25 years

                                                                                                               Health Care Expenditures ($1.27 trillion)




   Since 1900, life expectancy has increased by                                As a nation, we spend about $1.3 trillion
    30 years. According to the CDC, only 5 of                                    each year on health care. Less than 2% of
    those years can be attributed to curative                                    our health care expenditures are for
    medicine; the remaining 25 years are due to                                  population-based prevention activities.25
    public health and prevention measures.24                                     Although there are some programs in place
                                                                                 for early detection of disease and secondary
                                                                                 prevention, there is little attention paid to
                                                                                 preventing disease in the first place (primary
                                                                                 prevention).
Poor diet and inactivity raise health-care costs
Costs of Diet- and Inactivity-Related Diseases*                       Medicare costs are substantially lower for
                                                                       individuals at low risk for cardiovascular disease
Cancer12                                            $180 Billion       (i.e., who have low blood pressure and low
Coronary Heart Disease7                             $112 Billion       cholesterol in their 40s and 50s) than for individuals
                                                                       at high-risk. A study found that annual Medicare
Obesity9                                            $117 Billion       costs were, on average, $940 lower per person
Diabetes18                                           $98 Billion       for low-risk men than for high-risk men.
                                                                       Medicare costs were $1185 lower per person for
Stroke7                                              $49 Billion       low-risk women than for women at high risk.22
High Blood Pressure7                                 $47 Billion
Osteoporosis11,**                                    $14 Billion            Medicare & Medicaid Costs, 200023
    *Estimates of annual direct + indirect costs.
    **Figure includes direct costs only.                                Disease                          Cost

                                                                        Heart Disease                    $43.1 billion
     Employers pay an average of $4,410 more
                                                                        Cancer                           $18.8 billion
      per year for employee beneficiaries who
      have diabetes than for beneficiaries who do                       Diabetes                         $14.5 billion
      not have diabetes.19
                                                                        Stroke                            $7.0 billion

     According to the USDA, healthier diets
      could prevent at least $71 billion per                          As the U.S. population ages, the costs of diet-
      year in medical costs, lost productivity,                        and inactivity-related diseases will increase.
      and lost lives.20 CDC estimates that if all                      For example, the National Osteoporosis
      physically inactive Americans became                             Foundation expects the cost of osteoporosis to
      active, we would save                                            increase 20-fold by the year 2040.20
      $77 billion in annual medical costs.21
  Risk Factor Prevalence in the U.S.

             50
                                             High
             40
                                             Cholesterol
   Percent




             30
                                             Hypertension
             20
             10                              Smoking
              0
                                             Obesity
                  1960 1970 1980 1990 2000
                              Year



SOURCE: American Public Health Association
What does the obesity
epidemic mean to our
      children?
     Consequences of childhood
            overweight
   Medical complications
    • Joint problems
    • High blood pressure
    • Increased risk for Type II diabetes
    • Asthma
    • Hyperlipidemia
    • Sleep disorders
    • Increased risk for chronic disease later
      in life
     Consequences of childhood
            overweight
   Psychological consequences
    • Discrimination
    • Low self-esteem
    • Poor body image
    • Disordered eating


                          Eating disorders
     Consequences of childhood
            overweight
   Correlation between childhood
    overweight and adult overweight
    • 50% of overweight children and teens
      remain overweight adults
    • 26-41% of overweight preschool
      children will become overweight adults
            “Adult” diseases in children

                                                    Only 2% of children eat a healthy diet
                                                     (i.e., a diet consistent with federal
                                                     nutrition recommendations)28 and 35%
                                                     are physically inactive.29

                                                    25% of children ages 5-10 years
                                                     have high cholesterol, high blood
                                                     pressure, or other early warning
                                                     sign for heart disease.26



   Autopsy studies of teenagers and young adults have shown that virtually all have fatty
    streaks in their arteries (which is the first step toward clogged arteries). One in four
    study subjects had advanced fibrous plaques in their arteries.27

   Due to rising rates among children, type 2 diabetes can no longer be called ―adult onset‖
    diabetes. As the number of young people with type 2 diabetes increases, diabetic
    complications like limb amputations, blindness, kidney failure, and heart disease, will
    develop at younger ages (likely in their 30s and 40s).
      Adverse CVD Risk Factor
         Levels in Children
  Percent of children, aged 5-10, with 1
  or more adverse CVD risk factor levels:

                          27.1%
  Percent of overweight children, aged 5-10,
  with 1 or more adverse CVD risk factor levels:

                           60.6%
Source: Freedman DS et al. Pediatrics 1999; 103:1175-82`
Factors Related to the Onset of Obesity



•Heredity/Genes

•Increased dietary intake

•Decreased physical activity
              Genetics
 20-40% of Obesity Is Due to Genetic Factors


Humans have evolved genes
 favoring energy intake and
 storage.
70+ loci, genes, or markers
 may be involved in causing a
 susceptibility to obesity.
    Risk factors for
childhood overweight
What causes childhood
     overweight?


   Genetic predisposition
           AND
  Environment conducive to
        weight gain
Childhood Obesity: A Danger to
       America’s Health
Contributing Factors:
   •Food Practices
   •Nutrition/Serving Sizes
   •Lack of Physical Activity
   •Hours of Television per day/week
   •Family History
   •Race/Gender/Culture
Risk factors not amenable to
           change
 • Body type/growth potential
 • Other factors
     Ethnicity

     One or two obese parents

     Low household income

     Low parental education

     Older parents

     Few or no siblings
   Risk factors
amenable to change
             Risk Factors
   Things we can change
    • Parenting style
    • Eating patterns
    • Physical activity
    • Television watching
Parenting Style
         Two Parenting Styles
   High parental control over child’s
    appetite regulation
   Passive parenting regarding food
    selection and meal timing
        High Parental Control
   Risk of stunted growth
   Begging, sneaking or stealing food
   Preoccupation with food
   Overeating when food is not
    restricted
   Disordered eating
           Passive Parenting
   Related to history of food insecurity
   Increased child-led food selection
   12,000 new food products each year
Physical activity
             We are inactive!
          Europe and North America
           Percent of Trips by Mode
Country     Bicycle   Walking   Public   Car
                                Trans.
Netherlands 30        18        5        45
Germany     12        22        16       49
England     8         12        14       62
Italy       5         28        16       42
Canada      1         10        14       74
USA         1         9         3        84
Barriers to Physical Activity

    Peer influences
    Greater time demands
    Working parents
    Team sports becoming more
     competitive
    Availability of structured
     community programs
    Decreased activity in school
Daily PE Classes in Schools
     Year                       Percent


     1991                        42%


     1997                        27%




 Youth Risk Behavioral Survey
               Physical Fitness of California
                 5th, 7th and 9th Graders
                                    Grade 5                   Grade 7     Grade 9
                                   (n=2293)                  (n=2082)    (n=2047)
                                % in Healthy             % in Healthy   % in Healthy
 Tasks                          Fitness Zone             Fitness Zone   Fitness Zone
 Aerobic Capacity                      55.4                    53.4         59.7
 Body Composition                      70.6                    70.3         81.2
 Abdominal Strength                    82.9                    84.0         91.8
 Trunk Extension
 Strength                              87.6                    88.5         89.9
 Upper Body Strength                   67.4                    62.3         63.8
 Flexibility                           71.9                    72.7         77.5
 % of Students Meeting
 all 6 Fitness Standards               26.0                    27.1         32.9


SOURCE: CDE, 2001 California Physical Fitness State Report
U.S. SURGEON GENERAL’S PHYSICAL
       ACTIVITY SUGGESTIONS
   Plan family activities that provide everyone with
    exercise and enjoyment
   Provide a safe environment for your children and
    their friends to play actively; encourage swimming,
    biking, skating, ball sports, and other fun activities
   Reduce the amount of time you and your family
    spend in sedentary activities, such as watching TV or
    playing video games. Limit TV time to less than 2
    hours a day (AAP: no TV for <2 yr old)
   Accumulate at least 30 minutes (adults) or 60
    minutes (children) of moderate physical activity most
    days of the week
BENEFITS OF PHYSICAL ACTIVITY

  Regular physical activity in childhood and adolescence:

  •   Improves strength and endurance

  •   Helps build healthy bones and muscles

  •   Helps control weight

  •   Reduces anxiety and stress and increases self-esteem

  •   May improve blood pressure and cholesterol levels

  Young people say they like physical activity because it is fun;
    they do it with friends; and it helps them learn skills, stay in
    shape, and look better.
      CONSEQUENCES
   OF PHYSICAL INACTIVITY

• Number of overweight young people is rising.
• 300,000 deaths due to inactivity and poor diet.
• Less active adults are at greater risk for
  disease.
• Many young people do not participate in
  vigorous physical activity on a regular basis.
• The time students spend being active in
  physical education classes is decreasing.
  Fitness can mediate overweight risk
           Death Rates
Similar death rates between:
overweight & fit people compared to
lean & not fit people.
    Premature Death Risk
Overweight individuals can reduce
death risk by 66% if they become fit.
Eating patterns
         Eating patterns

   Increased meal skipping/restrained
    eating
   Increased random snacking
   Decreased family meals
   Increase in the consumption of
    high fat fast food, empty calories,
    and sodas
    • 27 to 44 gallons per year
    Trends in food consumption
   Increase in food eaten away from home
   Increase ―fast food‖ consumption
   Increase in food variety – 30,00 products
    in stores & 12,000 new products/year
   Expansion of portion sizes
   Ignoring portion sizes in restaurants
   Decrease in at home meal preparation
   Grazing
Changing dietary patterns:
        snacks
Kids are eating 25% of
their calories between
meals compared with
18% in 1970’s
Changing dietary patterns:
         foods
Snacks today are chips, french
fries, snack cakes, candy, soda
and fruit drinks as compared to
milk, sandwiches, cookies and
fruit in the 1970’s
                  Fast Food Restaurants
                    and Portion Sizes
   Marketplace food portions have increase
    in size and now exceed federal
    standards.
   Portion sizes began to grow in the
    1970s, rose sharply in the 80s and have
    continued to parallel with increasing
    body weights.



Source: American Journal of Public Health, February 2002, The Contribution of Expanding
Portion Sizes to the US Obesity Epidemic; Lisa R. Young, PhD, RD and Marlon Nestle,
PhD, MPH
Serving Sizes: U.S. vs. Great Britain
   A London newspaper compared typical serving sizes of
   foods in Britain to similar foods in the United States.




Source: Childhood and Adolescent Obesity in America: What’s a Parent To Do?; Betty
Holmes, MS, RD
       Beverages Available in the U.S. Food Supply
                 (Gallons/Person/Year)
       40
       35                 Milk
       30
       25
                          Regular Soft
       20                 Drinks
       15
                          Juice
       10                                     Diet Soft
       5                                       Drinks
       0          1970 1975 1980 1985 1990 1995

Source: U.S. Dept. of Agriculture, Economic Research Service Statistical
Bulletin No. 939, 1997
Healthy eating could
 reduce the costs of
heart disease, cancer
 and diabetes by an
      estimated
     $8.4 billion
 in California alone
Television watching
 TV viewing is increasing

             35
             30
             25
  Percent    20
Distribution 15
             10                                                                           NHES 1967-1970
              5                                                                           NLSY 1990
              0




                                                                               5+ hours
                  0-1 hours
                              1-2 hours

                                           2-3 hours
                                                       3-4 hours
                                                                   4-5 hours

                                          TV Hours
               Children and Television:
                     Distribution of Hours of TV Per Day:
                            NHES Youth Aged 12-17 in 1967-70 and
                35             NLSY Youth Aged 12-17 in 1990
                30
                25

  Percent 20
Distribution 15
                                                                     NHES 1967-70
                10                                                   NLSY 1990
                 5
                 0
                      0-1     1-2     2-3     3-4    4-5     5+
                            TV Hours (Youth Report)

Children spend more time sitting in front of electronic screens than any other activity
besides sleeping. The average time spent with various media (televisions,
computers, video games) is nearly four and one half-hours per day among two to 17
year olds. (Annenberg Public Policy Center, 1999)
 By kindergarten, children have
watched more than 5,000 hours of
           television
    Overarching
     Purpose:
   TO CALL THE NATION’S
     ATTENTION TO THE
 EPIDEMIC OF OVERWEIGHT
AND OBESITY AND IDENTIFY
   ACTIONS THAT WE AS A
  NATION CAN UNDERTAKE
  Overweight and Obesity:
   A Public Health Priority

Prevention or intervention to
 improve health
Need to be aware of social,
 cultural, and environmental
 influences
Must have access to family and
 community support
Everybody must do their share
       Obesity is a
     Chronic Disease
Often treated as a “subacute”
 illness, in which time-limited
 treatment will lead to a complete
 cure
Ineffective strategies to reduce
             obesity

   Weight loss diets

   Social isolation, ridicule, offensive
    jokes or other discrimination
    against fat people

   Reduction of fat in the American
    diet
    Prevention and
Intervention Strategies
Modification toward more
 healthful lifestyles
 • Increase “purposeful” activity
 • Decrease sedentary behaviors
 • Improve dietary choices
 • Use available support
   mechanisms
   Issues Influencing
   Behavioral Change
Appropriateness of messages
 • Reading level
 • Racially/ethnically correct
 • Scientifically sound
   Issues Influencing
   Behavioral Change
Consistency of messages
Motivation to adopt modified
 behavior
Availability of appropriate and
 accessible options or choices
Alarming Trends
Diets are falling short of
        the mark
Desirable physical activity
 levels are not being met
    Obesity rates are
      skyrocketing
   Adult diseases are
 showing up in children
What’s the best way to
approach the problem?

     Change the
     environment
         and
  Change individual
      behavior
    Addressing Childhood Obesity
   Create an environment to favor
    health

   Prevention, beginning at the
    youngest ages, is key. All
    children are at risk.

   Health - not weight - should be
    our focus
First Rule for Prevention
   and/or Intervention



   DO NO HARM!
     Who Should
     Be Involved?
Families
Schools
Businesses
Health care organizations
Communities
Media
Framework for Childhood Overweight Prevention
                          Legislation

                            Media
                        Urban Design &
                     Transportation Systems

                          Food Supply

                       Healthcare System
                          Community
                            Based
                            Schools
                             Home
     Environmental          & Family
        Change
                             The
                             Child
             The Child

   Individual change: education,
    motivation, skill building

   Environmental Change
                       Individual

   host factors:                   partners:
    • susceptibility
                                     biologists
    • hunger/satiety
    • metabolic factors              nutritionists
   focus on behavior change         psychologists
    •   physical activity
    •   inactivity
                                     exercise
    •   food choices
                                    physiologists
    •   food preferences
              Home / Parents

   Parenting
    • Provide opportunities for healthy eating &
      physical activity
    • Model healthy behaviors
   Support
    • Love and accept your child at every weight
    • Parenting classes, books, resources
               Family/Friends

   host factors:               partners:
    • genetics
                                 biologists
    • family environments
   focus on behavior change     psychologists
    •   physical activity        sociologists
    •   inactivity
    •   food choices
    •   food preferences
    •   eating environment
        Communities
Cultural and environmental
 influences
Access to safe activity
Access to support mechanisms
                   Community

   schools                    partners:
    • school environment
    • physical education        educators
    • nutrition education       attorneys
   neighborhood safety
    • genetics                  sociologists
    • family environments
   focus on behavior change
    •   physical activity
    •   inactivity
    •   food choices
    •   eating environment
          Worksite
Support of infrastructure for
 families and communities
Data on work efficiency
Value for the money
Wellness programs
    Preschools and Child Care
WIC, Head Start, State Preschool, Child Care
   Foods
   Education for children & families
   Opportunities for physical activity

   Institutional changes & community activities
           Schools
Food Service
  • Pricing
  • Vending machines
Activity
  • General
  • Intramural
  • Varsity
Health Education
                    Schools: K -12
   School Breakfast and Lunch Programs
   Healthy snacks (classroom rewards, student stores, vending
    machines, food sold at fundraisers)

   Education & teacher training
   PE classes, equipment and space


    • California Physical Fitness Test Results:
      http://www.cde.ca.gov/statetests/pe/pe.html
                   Schools: K-12

   Project LEAN

   Garden in Every School (CDE)
    • www.cde.ca.gov/nsd/nets/g_index.htm

   SHAPE (CDE)
    • http://www.cde.ca.gov/nsd/nets/sh_index.htm

   California Nutrition Network
    • http://www.dhs.cahwnet.gov/cpns/programs/nutrition/nutrition.htm
Vending Machines in MA Schools
100
                                          Beverage
 80                                       Food

 60


 40


 20


  0
      Elementary   Middle   High School
          Community Based
   Cities’ Parks & Recreation, and Planning Depts

   County Public Health

   Youth programs

   Churches

   Neighborhood organizations

   Community based organizations/non-profits
              Community Based

   CANFit: grants to programs serving minority youth, 10-14 yrs old.

   5-a-Day Power Play: OC - UC Coop. Extension reaching low-
    income 9-11 year olds
   “Spring Into Health” Day: American Cancer Society

   Project LEAN & California Nutrition Network: targeting low-
    income families
           Health Care System


   Health care professionals

   Health care institutions (hospitals, clinics, etc.)

   Insurers
                  Society/Policy
   Physical environment
    •   neighborhood design    partners:
    •   transportation
                                   urban planners
    •   genetics
    •   family environments        engineers
   Social Environment
                                   architects
    • neighborhood safety
    • food choices                 attorneys
    • eating environment
                                   ethicists
   Taxation/Regulation
    • taxes/price supports         sociologists
    • open space laws
                  Food Supply
   Food producers, farms, community gardens
   Grocery stores, farmers markets, etc.
   Restaurants
   Food assistance programs (WIC, food stamps,
    food banks, commodity foods)
          Urban Planning and
        Transportation Systems

   Sidewalks, crosswalks
   Bicycle and walking paths
   Parks and open spaces
   Community lay-out and access to services
   Safety (traffic safety, law enforcement, lighting)
Community Structure and Physical Activity
                     Media

   Advertising/commercials

   Reduced Viewing
    • TV Turn Off Network: www.tvfa.org/index.html



   Media Advocacy
      Media and
    Communications
Improve recognition and
 translation of what is
 important
 • Media emphasizes conflict
 • Conflicts often presented without
   appropriate filter
Terminology
Success stories
                  Legislation

   Regulations

   Funding

   Taxes (incentives and disincentives)
          Changing the Rules
           to Favor Health

   Incremental & fundamental changes

   Complex problem with a variety of solutions

   Coordinated efforts
    Truisms of childhood overweight
   We all “own” the problem
   We all have responsibility to impact
    this problem
   Coordination and collaboration is
    essential
The Coalition Approach

                   Legislation


                      Media



       Urban Design & Transportation Systems


                   Food Supply


                Health Care System


                   Community


                      School


                  Home & Family



                    The Child
Interventions to prevent and treat
 overweight are designed to help
people change their behaviors and
  maintain theses changes. But
 behavior is resistant to change.
Health educators have
been successful teaching
about the risk of an
unhealthy diet and
inactive life, however
they have had little
success in helping
individuals change these
high-risk health
behaviors.
Examples of successful health
behavior changes:
Smoking cessation decreased only
with changes in environment –
cigarette taxes, smoke-free areas
Rate of automobile injuries
decreased only after changes in
speed limits and seat belt laws
were made.


Community education programs
supported these changes.
Finland is an example of successful
community health intervention.
Community members designed
intervention to include structural
changes to food supply:
Change in fat content of meat.
Change in fat content in dairy.
The death rate from heart disease was
reduced by 60%.
Puska et al 1985
Community approach calls upon the
strengths and diversity of the community.
The key to success is the fact that it comes
from the bottom up rather than the top
down.
Communities that initiate their own
interventions make them specific to their
own lives and social circumstances.
What’s needed to take a
community approach:
Use resources already available.
Harness and redirect existing resources to
achieve the goal.
Build community capacity – sum of
resources, people, organization, institutions
and natural resources that can be mobilized
to improve local conditions.
    Stages of Community Changes
•   Receptivity – Community open to
    change. Acknowledge things can be
    better.




Search Institute
www.search-
institute.org
    Stages of Community Changes
•   Awareness – Community has
    background knowledge and
    information. They understand what
    needs to be changed and recognize
    the role they can play in the effort.
Stages of Community Changes
   Mobilization – Like minded
    community members come
    together to create change.
    Activities include team
    building, identifying
    potential resources,
    setting goals and
    developing strategies.
Stages of Community Changes
   Action – Community members take
    action to achieve their goals.
Stages of Community Changes
   Continuity –
    Community
    members engage
    in activities to
    ensure that the
    change process
    continues.
    Activities include
    monitoring and
    celebrating the
    progress.
 Why Should Groups
  Work Together?
Efficiency and common resources:
 • Many groups are consulting with
   the same experts
 • Many groups are seeking support
   from the same sources
 • Many goals are overlapping
 • Improved consistency of efforts
Successful community approaches
 to address childhood overweight.
   Target all children, not just those who are
    overweight.
   Focus on environmental changes that
    promote healthy, active lifestyles among
    youth.
   Involve individuals and groups throughout
    the community who represent a broad
    range of backgrounds expertise and
    experience.
      More successful strategies
   Be holistic in approach,
    since child overweight is
    connected to physical
    health AND to social and
    mental well being.
   Use a variety of
    approaches, since this is a
    complex problem with
    many causes.
Conduct a community assessment.
   Assess your community’s receptivity
    – take the pulse of your community.
    Ask probing questions.

   Catalog your community’s assets.

   Create a resource binder.
        Assemble the Coalition
   Who to invite?
    • Politicians
    • School Personnel & Volunteers
    • Health Professionals
    • Community Organizations


   Clearly state the coalition’s vision
    and mission.
 Monitoring Our Status
Leading Health Indicators within
 Healthy People 2010 – Annual
 Report Card
Subpopulations
Measured versus self-report
Cross-sectional versus
 longitudinal
Modification of health risks
                               Summary
 Two-thirds of premature deaths in the U.S. are due to poor nutrition,
  physical inactivity and tobacco use. Federal and state governments
  conduct effective programs to reduce tobacco use, but do little to promote
  healthy eating and physical activity and reduce obesity.

 Obesity is one of the biggest public health challenges of our time.

       Overweight and obesity affect the majority of American adults (61%).

       Obesity is the nation’s fastest rising public health problem. Obesity rates
        among U.S. adults increased by 60% between 1991 and 2000 and rates doubled in
        children over the last 20 years.

       The negative health consequences of rising obesity rates are already evident.
        Rates of diabetes (most of which is type 2, which is largely due to obesity, poor
        diet and inactivity) rose 50% between 1990 and 2000.

       All states must be funded by the CDC as soon as possible to promote healthy
        eating and physical activity and reduce obesity. Currently, only twelve states
        are funded.
 Existing HHS nutrition and physical activity
programs
     While one-third of premature deaths in the U.S. are attributable to poor nutrition and
      physical inactivity, funding for the CDC’s Division of Nutrition and Physical Activity
      represents less than 1% of the CDC’s total budget and is less than 4% of the CDC’s chronic
      disease budget.

          FY 2002 funding for the CDC’s Division of Nutrition and Physical Activity is $27.6 million. The
           program includes funding for applied research, surveillance, national communications, 12
           state-based programs (in CA, CO, CT, FL, MA, MI, MT, NC, PA, RI, TX, WA) funded at a core
           level and programs to reduce micronutrient deficiencies world-wide. In comparison, CDC’s
           program to discourage tobacco use has a
           FY 2002 budget of $101 million and provides funding for every state.

          Although the nutrition and physical activity program has grown by $5-10 million
           per year over the last three years, at the current rate of growth it would take seven
           to ten years to fund all states. Over the past decade, obesity rates have increased by
           60% and diabetes rates by 50%.6

     Funding for the CDC’s Youth Media Campaign decreased from $125 million in FY 2001 to $68.4
      million in
      FY 2002. The campaign will use paid television, radio and print advertising, an interactive web
      site, and community events and programs to encourage children to make healthy lifestyle choices,
      with an emphasis on physical activity.

     The National Cancer Institute’s 5 A Day program has a FY 2002 communications budget of $1
      million to promote the intake of fruits and vegetables. Fruit and vegetable intake is an important
      means of preventing cancer, heart disease, and other diseases.

     The President’s Council on Physical Fitness and Sports has a FY 2002 budget of $1.1 million.
Programs that promote healthy eating and
activity can be economical and effective.
                                       Mass-Media Approaches
  A seven-week 1% Or Less campaign in Clarksburg, West Virginia, doubled the community's
   low-fat milk consumption from 18%
   to 41% of milk sales. The campaign used paid advertising; public relations; and community
   programs, and cost just 22 cents per person.


  As a result of a 1999 mass media campaign by the Arizona Nutrition Network to promote fruit and
   vegetable intake to food stamp recipients, consumption of 5 or more servings of fruits and
   vegetables per day increased by 127% among individuals with incomes of less than $15,000
   per year, and by 200% among individuals with incomes between $15,000 and $19,999 per
   year.

  Wheeling Walks, an eight-week population-based campaign to promote walking in Wheeling,
   WV, used paid advertising and public relations activities supported by programs at worksites and
   other community organizations. The campaign resulted in a 15% increase in the number of
   people who reported walking at least 30 minutes per day on 5 or more days per week as
   compared to the control city.

  A campaign sponsored by the Florida Department of Health used advertising, advocacy and
   public relations to discourage youth smoking. The campaign resulted in a 19% reduction in
   smoking rates of middle school students and an 8% decline in smoking among high school
   students.
Programs that promote healthy eating and
activity can be economical and effective
         Physical Activity & Nutrition Promotion


 A curriculum taught to middle school students in
 Massachusetts integrated health promotion messages into
 traditional lessons, such as math, science, and language arts.
 The curriculum effectively reduced obesity prevalence by
 3.3% among girls (contrasting with a 2.2% increase in
 obesity prevalence in the control group), increased fruit and
 vegetable consumption among girls, and reduced hours of
 television viewing among both girls and boys.
 Saint Louis University's Prevention Research Center built 17
 walking trails in rural communities in Missouri to provide safe
 and convenient places to exercise. Survey data show that
 42% of community residents use the trails and 60% of trail
 users report that they are more physically active since
 the trails were built.
      First steps toward reducing obesity and
    other diet- and inactivity-related diseases:
               What Congress can do?
   Support a FY 2003 appropriation of $60 million for the CDC to promote
    healthy eating and physical activity and to reduce obesity. Increased
    resources are needed to fund all states. $60 million would allow the
    CDC to fund 20 states at a core level and 4 states at an enhanced
    level. Currently, only 12 states (CA, CO, CT, FL, MA, MI, MT, NC, PA,
    RI, TX, and WA) are funded (all at a core level). Funding is also
    needed to further develop, test, and disseminate practical
    interventions and effective policies, to conduct surveillance and
    communications campaigns, and to strengthen the CDC’s 5 A Day
    program.

   Provide the CDC with a FY 2003 appropriation of $125 million to
    restore the Youth Media Campaign, which uses modern marketing
    techniques to promote physical activity to youth, and begin message
    and program development for a fruit and vegetable campaign.


                               “We need to act, individually and as a nation,
                               to prevent obesity and diabetes.”
                               - HHS Secretary Tommy Thompson, September 2001
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