Childhood Obesity Education For African-American Youth At A Neighborhood Health Fair Background Obesity in children and adolescents has emerged as one of the most alarming health concerns facing our country today. The proportion of children and adolescents that are overweight or obese is now higher than ever before due to an accelerating obesity rate over the past twenty-five years; specifically, the prevalence of obesity has quadrupled among children aged 6-11 and more than doubled among adolescents during this period.1 In 2001, Surgeon General David Satcher, M.D., Ph.D. expressed in his “Call to Action to Prevent and Decrease Overweight and Obesity” that overweight and obesity had reached epidemic proportions among all population groups with an estimated 61 percent of adults overweight and 15 percent of children and adolescents considered overweight.1 These estimates are consistent with data obtained from the 1999-2000 National Health and Nutrition Examination Survey (NHANES), which reported that overweight and obesity affected 15.5% of 12- to 19- year olds, 15.3% of 6- to 11- year olds, and 10.4% of 2- to 5- year olds.2 These population estimates of overweight and obesity are even higher today. The etiology of the pediatric obesity epidemic remains multi-factorial. Obesity is conventionally defined in terms of body mass index (BMI), with a sex- and age-specific BMI at or above the 95th percentile considered overweight or obese. An individual’s weight is determined by genetic, environmental, metabolic, behavioral, cultural, and socioeconomic factors.1 Behavioral trends such as increased caloric intake, decreased physical activity, excess intake of dietary fat, and increased consumption of carbohydrates have been widely implicated as causative factors for childhood obesity. However, the overall contribution of each of these 2 factors remains ambiguous. A review by Slyper3 argues against increased caloric intake as the prime causative factor of obesity. The author cites the Bogalusa Heart Study, a long-term cohort study of cardiovascular risk factors in both white and African-American youth, where the total caloric intake of 10 year-olds remained virtually unchanged from 1973-1988 despite an increased incidence of obesity. The pediatric obesity epidemic in the United States is most concerning for its resulting morbidity among children and adolescents. Obesity-associated diseases in youth accounted for hospital costs of $127 million from 1997 to 1999 while numerous studies have shown that obese individuals have a 50-100 percent increased risk of premature death from all causes compared to individuals with a normal BMI.4 The medical complications of childhood obesity include the following: cardiovascular diseases such as dyslipidemia and hypertension; respiratory diseases such as sleep apnea and Pickwickian syndrome; increased incidence of insulin resistance and type 2 diabetes mellitus in youth; slipped capital femoral epiphysis and other musculoskeletal pathology; and gastrointestinal diseases such as steatohepatitis and cholelithiasis. The development of early-onset hypertension, dyslipidemia, and diabetes markedly increases the likelihood of heart disease in adulthood. For example, the Bogalusa Heart Study discovered that childhood obesity is a major predictor for the development of the metabolic syndrome (central obesity, dyslipidemia, hypertension, insulin resistance) in adulthood.5 An increased rate of development of type 2 diabetes mellitus has paralleled the rising number of overweight children and adolescents. The early onset of type 2 diabetes results in an increased susceptibility to complications such as diabetic retinopathy, neuropathy, nephropathy, and atherosclerotic heart disease.6 The most significant morbidities affecting overweight youth, however, may be 3 psychosocial with effects such as poor self-esteem, social isolation, and depression common among these children and adolescents. Disparities within the pediatric obesity epidemic exist in the United States based on race and ethnicity. African-American, Hispanic American, and Native American children and adolescents suffer from proportionally high rates of obesity. Among 2- to 5- year-olds in the NHANES study (1999-2000), the prevalence of overweight children by race was 8.6% in non- Hispanic whites, 8.8% in non-Hispanic blacks, and 13.1% in Mexican-Americans.2 The findings are more striking among 12- to 19- year-olds, where significantly more non-Hispanic black (23.6%) and Mexican-American (23.4%) adolescents were overweight compared to non- Hispanic white adolescents (12.7%). Moreover, the onset of obesity during childhood is significantly earlier among the African-American population. A cohort analysis by Saha et al7 showed that 25% of blacks were overweight/at risk for overweight at or before the age of 7. In comparison, 25% of white males and females became overweight/at risk for overweight not until ages 10 and 11, respectively. Background of Targeted Community The state of New York and Monroe County are not immune to the childhood obesity epidemic. Approximately 28% of New York high school students are overweight or at risk of becoming overweight while 33% of low-income children between 2 and 5 years of age are overweight or at risk of becoming overweight.8 The 2003 Youth Risk Behavior Survey 9 found that 36% of students did not participate in sufficient vigorous physical activity (>20 minutes on >3 of the past 7 days) and 77% did not participate in sufficient moderate physical activity (>30 minutes on >5 of the past 7 days). 4 The Northeast Quadrant of the City of Rochester consists primarily of African-American residents experiencing high rates of poverty, crime, violence, and unmet health care needs. According to data obtained from the 2000 Census,10 the median income for a household in this region is $31,909. The median family income is $36,231 and the per capita income was reported to be $17,768. Approximately 10.5% and 8.7% of individuals and families living in this census tract, respectively, are below the poverty line.10 As a result of the high prevalence of poverty and limited access to health care in this community, Preferred Care insurance sponsored a health and human services fair at the Frederick Douglass Preparatory School on August 27, 2005 in cooperation with the University of Rochester/Strong Health and many local organizations. The event featured a job fair, free health screenings, booths dedicated to disseminating health information, prayer groups, and various activities for children. With a large audience from a target population, this health fair was an excellent means to educate parents and youth on childhood obesity. Project Description / Methods / Partnerships My project involved the planning, designing, and staffing of a health fair booth addressing childhood obesity education at the First Annual Preferred Care – Northeast Quadrant Health and Human Services Fair. I was initially unsure of the best location to conduct such a project and asked Gabrielle Kapsak, the clerkship coordinator, for any suggestions. She informed me that CHIC had already reserved a booth at the Northeast Quadrant health fair, and I believed this would be an excellent site in a target neighborhood to influence a large number of people. I initially gathered background information on the scope and causes of the growing epidemic of pediatric obesity by browsing the medical literature and many websites. In order to ensure that the information was reliable, I directed my search at various governmental sites such 5 as the Centers for Disease Control and Prevention (CDC). The most comprehensive background resource was the US Surgeon General’s 2001 “Call to Action to Prevent and Decrease Overweight and Obesity” (available at http://www.surgeongeneral.gov/topics/obesity). The report outlines the epidemiology, disparities in prevalence, and health risks of pediatric obesity and offers public health strategies designed to address the problem. Another excellent source was the CDC’s resource on childhood obesity (available at http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm), which provided useful information on trends, contributing factors, and consequences. After acquiring knowledge of the problem, I focused my efforts on planning and designing the health fair booth. While searching the Internet for background information, I discovered a number of sites with both printable brochures and online catalogs of publications. The US Department of Agriculture’s Team Nutrition program (http://www.fns.usda.gov/tn) as well as the Weight-Control Information Network of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (http://win.niddk.nih.gov) provided many free resources. After contacting both organizations by phone and relaying my task, I was able to order almost one hundred brochures as well as books, bookmarks, pens, stickers, and activity sheets for children. My major partnership for this project was the Rochester office of the American Heart Association. As the community affairs coordinator for the American Heart Association, Tamiko Byrd was an excellent source for educational materials and project planning. I met with Tamiko early on in the project and several times later to best ensure the ordering of materials and project coordination. Overall, she was able to provide me with a tri-fold display board, numerous posters and activity sheets for children, a scale to measure children’s BMIs, a model heart with chambers that opened up, and American Heart Association brochures on topics such as “For 6 Your Children”, “Six Steps to A Healthy Heart”, “Nutritious Nibbles”, and “Shop Smart With Heart”. Tamiko is an enthusiastic and wonderful person, and I truly enjoyed partnering with her on this project. She provided me with a lot of autonomy in designing the theme and actual health fair presentation. As a result of my project, the American Heart Association decided not to operate a separate booth on another health topic. Another valuable partnership was with the Cornell Cooperative Extension on Highland Avenue in Rochester. Focused mainly on agriculture, the group also runs a campaign dedicated to healthy eating and nutrition. I contacted Dora Christian, the head of the nutrition education program, by phone. She was eager to assist and was an excellent source of activity sheets for children, informational brochures, posters of the newly revised food pyramid, and healthy recipes for parents. She also directed me to a number of useful websites dealing with nutrition. I also formed a partnership with the Golisano Children’s Hospital Outpatient Pediatric Nutrition Services. I initially sought the advice of one of my former inpatient pediatrics attendings, Dr. Peter Szilagyi, regarding the best individual that could assist me. He introduced me to Bamini Pathmanathan, one of the outpatient pediatric clinical nutritionists, who provided me with some educational materials on obesity that I was able to photocopy and distribute at the health fair. Her materials on food portions and sample menus were particularly helpful. I also contacted the Nutrition/Weight Management Center at Strong. Unfortunately, as all of their materials were directed towards advertising their program, they were unable to assist me. Finally, as I was securing materials during the week before the health fair, I decided to contact both the Tops Market in Brighton and Kinko’s on Jefferson Road to assess their willingness to place a donation for my health fair booth. The manager of Tops, Adair McCarthy, donated a $25 shopping card for use in her store. In order to better attract parents and children to 7 my booth, I decided to purchase both bottled water and pretzel rods as an example of a healthy snack. Kinko’s generously designed an 8’ x 2’ banner reading “Kids Eating Healthy” for use in advertising my booth. I was truly impressed by the generosity exhibited by these local businesses. Implementation Upon arrival at the Frederick Douglass Preparatory School at 9:00 AM, I was assigned a table under a tent containing all Strong-affiliated programs including dentistry, breast cancer awareness, and poisoning prevention. Preparations for the event took place from 9:00-10:30 AM with the health fair occurring from 11:00 AM to 4:00 PM. I utilized the tri-fold display board provided by the American Heart Association to display a number of attractive, educational posters such as the newly revised USDA food pyramid and another describing the amount of exercise required to “burn off” a given food. The banner donated from Kinko’s prominently displayed the theme of the booth, and free Aquafina bottled water and pretzel rods were distributed. The free bottled water proved to be a great success in attracting individuals to my booth. It was an extremely hot afternoon, and I gave away almost 100 bottles of water! A wide range of informational brochures from the American Heart Association, USDA, and CDC were available for parents and kids. A number of parents were particularly interested in the pamphlet called “Helping Your Overweight Child” that offered tips on how to encourage your child to eat healthy and provided examples of healthy alternative snack foods. I was initially concerned that the number of American Heart Association brochures would be insufficient; however, the majority of patrons were interested in taking the USDA and CDC materials plus kids’ activity sheets containing crossword puzzles, word searches, and other age- 8 appropriate games. Each younger child was given a sticker, pen, and bookmark displaying the healthy eating theme. Furthermore, I designed an interactive game in which kids (and parents!) were challenged to match Ziplock bags containing measured teaspoons of sugar to their corresponding beverages such as Coca-Cola, Snapple Iced Tea, Gatorade, Diet Pepsi, and bottled water. In addition, two American Heart Association books entitled “No-Fad Diet: A Personal Plan for Healthy Weight Loss” were raffled off by having individuals pick the winning ticket from a jar full of tickets. Besides offering free bottled water and pretzels, I performed BMI measurements on interested children and adolescents. After receiving their BMI, individuals received an informational sheet describing how the BMI is used and their category of weight (see appendix). Community Reaction / Feedback My booth at the First Annual Preferred Care – Northeast Quadrant Health and Human Services Fair promoting awareness of pediatric obesity and healthy eating proved to be a great success. The health fair served as an excellent forum to educate a large number of residents from a target population – I gave away around 100 bottles of water and had almost 300 individuals total stop by to look at my booth and materials! As a community struggling with poverty and limited access to health care, the residents seemed extremely interested and grateful for the work done by the volunteer vendors. In regards to my booth, I found both children and parents to be genuinely interested in learning more about healthy eating and receptive to nutritional advice. For example, several adults had never seen the newly revised food pyramid and listened as I instructed them on the changes from the previous version. I was able to assist a mother with three young children under the age of 5 who expressed frustration in interpreting nutritional content labels. Both children 9 and adults enjoyed the challenge of matching the drink with its sugar content. Everyone was astonished, for instance, that a 20-ounce bottle of soda contains 17 teaspoons of sugar and that Gatorade contained any sugar at all! I am hopeful that viewing firsthand the amount of sugar in popular beverages will lead to better selections in the future. One of the most rewarding experiences was observing the children’s enthusiasm and interest in learning about the model heart. The majority of the kids had never seen a model such as this and listened attentively as I showed them the various chambers and the path of blood flow. One young boy even asked if he could take it home with him! Furthermore, I found the poster detailing the amount of exercise required to burn off the calories in foods such as French fries and jelly donuts to be highly effective for both children and adults. I also performed BMI measurements as part of the booth; however, only a few children were interested in obtaining their BMI. Many of the children, especially those overweight, were hesitant to have their weight checked due to the large number of people around. The young children for the most part only wanted to stand on the scale for fun. Due to the large number of booths, families did not tend to spend much time at any single location. Nevertheless, some children did take advantage and were given an informational sheet describing the uses of the BMI. Sustainability Overall, I believe the First Annual Preferred Care – Northeast Quadrant Health and Human Services Fair was an excellent vehicle to disseminate health information to a large number of residents with unmet health care needs. After speaking with one of the health fair organizers, I am confident that this venue will become a yearly occurrence. The concept of utilizing a health fair booth to disseminate information about pediatric obesity and healthy eating is a sustainable and worthwhile CHIC project. Since this health fair 10 could become an annual event in this community, another CHIC student could further the impact that I made by conducting a similar project next year dealing with pediatric obesity education. Through repetition, the community may come to realize the importance of this health problem. As evidenced from a fourth year student last year, the model can also be used for smaller audiences such as schools and the JOSANA area or expanded to meet the needs of a larger audience such as this health and humans services fair. Discussion My intensive four-week community health improvement project consisted of a health fair booth addressing pediatric obesity education for African-American youth at the First Annual Preferred Care – Northeast Partners Health & Human Services Fair. My project fulfilled nearly all of the defined clerkship learning objectives. My health fair booth addressed a significant community health issue affecting the Northeast Quadrant residents of the City of Rochester. As addressed by the Surgeon General, pediatric obesity has accelerated to epidemic proportions in the United States and has disproportionately affected the African-American community. My goals were to distribute information about the pediatric obesity epidemic and to promote risk behavior change in the form of healthy eating and physical activity for children and adolescents. The stated objective to learn how to assess and control common community health problems was addressed by reviewing public health strategies for pediatric obesity in the literature and by developing approaches to educate individuals about this problem as part of my health fair booth. Furthermore, I successfully developed a number of partnerships with prior CHIC-affiliated organizations such as the American Heart Association and the Cornell Cooperative Extension while also establishing new relationships with Outpatient Pediatric Nutrition at Strong, Tops Markets, and FedEx-Kinko’s. As addressed previously, I believe that my health fair booth 11 addressing pediatric obesity could prove to be an excellent and sustainable means of addressing health education needs in this target community for years to come. Even by conducting just this single event, I am hopeful that my educational efforts will have an impact on both children and parents. As evident by the hundreds of people that visited and took materials from my booth, I am optimistic that my project had a positive and sustainable impact on the Northeast Quadrant community. I am convinced that the residents of this community, despite lacking access to health care, are undoubtedly interested in health promotion and learning strategies to combat the growing epidemic of pediatric obesity. By engaging in BMI measurements and other hands-on activities, the community members may now realize the health implications of pediatric obesity and incorporate simple interventions such as drinking diet sodas and low-fat cooking methods in their daily lives. As seen from the enthusiasm of the young children in learning about the heart, the challenge inherent in changing any health habit lies in making it fun. My community health improvement project had a large impact on myself as well. As I am interested in pursuing a career in Cardiology, I enjoyed the opportunity to learn more about the underlying etiologies, trends, and health impact of pediatric obesity. I witnessed the generosity and community spirit exhibited by the local organizations that formed partnerships with me. The opportunity to work with the Northeast Quadrant community was truly rewarding for me. One of the most satisfying experiences was counseling a grandfather with two overweight grandchildren on how to encourage them to eat healthy and be physically active. He described how they were picky eaters and preferred unhealthy foods such as chocolate milk, regular soda, and hamburgers. I appreciated his sincerity, and it was then that I understood the difficulties inherent in behavioral change. Finally, the opportunity to interact and learn about 12 this community was truly worthwhile in helping me to grow both as a future physician and as a person. 13 References 1. U.S. Department of Health and Human Services. The Surgeon General’s Call To Action To Prevent and Decrease Overweight and Obesity. U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001. Available at http://www.surgeongeneral.gov/topics/obesity/calltoaction/CalltoAction.pdf 2. Ogden CL, Flegal DM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002;288:1728-1732. 3. Slyper, AH. The pediatric obesity epidemic: causes and controversies. J Clin Endocrinol Metab 2004;89:2540-2547. 4. Schneider MB, Brill SR. Obesity in children and adolescents. Pediatrics in Review. 2005;26(5):155-161. 5. Srinivasan SR, Myers L, Berenson GS. Predictability of childhood adiposity and insulin for developing insulin resistance syndrome (syndrome X) in young adulthood: The Bogalusa Heart Study. Diabetes. 2002;51:204-209. 6. Hannon TS, Rao G, Arslanian SA. Childhood obesity and Type 2 diabetes mellitus. Pediatrics. 2005;116(2):473-480. 7. Saha C, Eckert GJ, Pratt JH, Shankar RR. Onset of overweight during childhood and adolescence in relation to race and sex. J Clin Endocrinol Metab 2005;90:2648-2652. 8. Centers for Disease Control and Prevention. Overweight and Obesity: State-Based Programs – New York. http://ww.cdc.gov/nccdphp/dnpa/obesity/state_programs/new_york.htm. Accessed August 29, 2005. 14 9. Centers for Disease Control and Prevention. Surveillance Summaries, May 21, 2004. MMWR 2004;53:1-96. Available at.http://www.cdc.gov/HealthyYouth/yrbs/index.htm. Accessed August 29, 2005. 10. U.S. Census Bureau, Fact Sheet for Census Tract 83.01, Monroe County, New York. http://factfinder.census.gov. Accessed August 29, 2005. 15 Appendix 1. Confirmation letter for attendance at health fair 2. Partnership contact information 3. Letter to Tops 4. BMI interpretation handout 5. Sample brochures 16 and Northeast Partners “Family Fun Day” Health / Human Service & Job Fair Saturday, August 27, 2005 11:00am – 4:00 pm at Frederick Douglass Preparatory School, 940 Fernwood Park Rochester, New York 14609 Dear Community Partner: Thank you for supporting the First Annual Northeast Quadrant Family Fun Day Health & Human Service/Job Fair. Please note that this is a rain or shine event, which will be held on Saturday August 27, 2005 11:00am to 4:00pm at 940 Fernwood Ave, Rochester NY 14609. We have your agency confirmed with one 8’ table and 2 chairs. Additional tables will be provided based on your sponsorship level, however your request must be made in advance. Since this is a Community Faith-Based Initiative Project, we are asking that you adhere to the following: No Condoms at the display tables (abstinence related material is welcome) No Needle exchange materials No Campaign material No sales please Free give always are welcome Set-up times 9:00 am - 10:15 am. Volunteers will be available to help load and unload There will be one identified entrance for agency representatives who are setting up tables Free food and bathrooms will be available to vendors If possible please do not leave early. Be prepared to be in attendance at the event from 11am-4pm. Please feel free to call Adonai at (585) 454-2640 with any further questions or concerns. Once again, thanks for making a difference in our community! 17 Partnership Contact Information Tamiko Byrd American Heart Association 2113 Chili Avenue Rochester, NY 14624 (585) 697-6281 Tamiko.Byrd@heart.org Dora Christian Community Nutrition Supervisor Cornell Cooperative Extension – Monroe County 249 Highland Avenue Rochester, NY 14620 (585) 461-1000 ext. 257 email@example.com Bamini Pathamanathan Outpatient Pediatric Nutritionist – Golisano Children’s Hospital (585) 275-3909 Tops Friendly Markets c/o Adair McCarthy 1900 South Clinton Avenue Rochester, NY 14618 (585) 442-2990 FedEx - Kinko’s 941 Jefferson Road Rochester, NY 14623 (585) 240-2679 18 August 22, 2005 Ryan Anthony 4th Year Medical Student University of Rochester School of Medicine 601 Elmwood Avenue, Box 215 Rochester, NY 14642 Tops Markets 1900 South Clinton Avenue Rochester, NY 14618 Dear Ms. McCarthy: I am a fourth year medical student at the University of Rochester currently working on a project dealing with pediatric obesity and healthy eating for children. In partnership with the American Heart Association, I will be staffing a booth at the upcoming “Preferred Care – Northeast Quadrant Health Fair” being held on Saturday, August 27th at the Frederick Douglass Preparatory School in northeast Rochester. The health fair is targeting an underserved neighborhood, and my booth will be distributing a number of educational materials dealing with healthy eating as well as measuring children’s heights and weights. As I spoke with you this morning, I would like to see if you would be interested in providing some healthy snacks for my health fair booth. The opportunity for children to try healthier foods is an important step in changing eating habits in the long-term. I would be pleased to have any trail mix, dried fruit, pretzels, or bottled water or perhaps a gift card that you could provide. Please contact me with any questions. I can be reached at (585) 427-8043. I appreciate your time and consideration. Sincerely, Ryan Anthony 19 How To Interpret Your BMI Your BMI today is _________ Your BMI percentile-for-age is _________ Body mass index (BMI) is a calculation that uses your height, weight, and age to estimate how much body fat you have. Too much body fat is a problem because it can lead to illnesses and other health problems. BMI, although not a perfect method for judging someone's weight, is often a good way to check on how a kid is growing. BMI is particularly helpful for identifying children and adolescents who are at risk for becoming significantly overweight as they get older. In older children and teens, there is a strong correlation between BMI and the amount of body fat. Therefore, those with high BMI readings - and probably high levels of fat - are most likely to have weight problems when they are older. If doctors can identify these at-risk children early on, they can monitor their body fat more carefully and potentially prevent adult obesity through changes in eating and exercise habits. Calculating BMI The best way to determine your BMI is to have your doctor do it for you. That way, you'll know the number is accurate and your doctor can discuss the result with you. Once you have calculated your BMI, you'll learn that you are in one of 4 categories: Underweight: Less than the 5th percentile Healthy weight: Between the 5th and the 85th percentiles At risk for overweight: Between the 85th and 95th percentiles Overweight: Higher than the 95th percentile Where BMI Can Fall Short BMI is not the whole story when it comes to someone's weight. A more muscular kid may have a higher weight and BMI but not have too much body fat. Also, a smaller kid could have an ideal BMI, but might have less muscle and too much body fat. Because there are other considerations, it's a good idea to rely on your doctor if you have questions about whether you are at your ideal weight. If your doctor tells you your BMI is high, don't let it get you down. Instead, talk to your doctor about what you should do to lower your BMI. Unlike adults, kids don't usually need to diet. But by eating healthier and getting more exercise, a kid can improve his or her BMI. Controlling a weight problem while you're still a kid can help you avoid becoming an overweight adult and developing health problems like diabetes and heart disease.
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