Play Now or Pay Later: Prevention and Interventions in the Childhood Obesity Epidemic

1. Play Now or Pay Later:Prevention and Interventions in the Childhood Obesity Epidemic Rita Berthelsen, PhD, RD, LMNT Director, Hospitality Services

2. Objectives for Presentation Following this presentation, the participant will be able to: • Describe multifactorial causes of child obesity in the United States. • Discuss correlation of childhood minutes spent in family interactions, fitness activities and sedentary audiovisual activities and the incidence of childhood obesity. • Examine the effectiveness of a multifactorial approach in the treatment of childhood obesity.

3. The Problem: Short and Simple Overweight is now more prevalent among children than underweight or growth delay even among low income. U.S. Surgeon General,Vice Admiral Richard H. Carmona, M.D., M.P.H., FACS

4. Ratio of weight in kilograms to the square height in meters Widely used to define overweight and obesity New CDC growth charts include BMI 85% – 95% risk of overweight > 95% obese Body Mass Index (BMI) (www.cdc.gov/growthcharts)

5. Obesity Trends* Among U.S. AdultsBRFSS,1990, 1995, 2005 (*BMI 30, or about 30 lbs overweight for 5’4” person) 1995 1990 2005 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: Behavioral Risk Factor Surveillance System, CDC.

6. Source: Omaha World Herald August 30, 2004

7. Nebraska Statistics2002 – 2003 School Year • 1/6 (16.5%) students K-12 is overweight • Another 1/6 is at risk for being overweight • Students at greatest risk: • Hispanic • Native Americans • South Central • African American NE HHS Survey

8. Prevalence of Overweight Children and Adolescents in the United States Ogden, et al,. (2002)

9. Ethnicity Influences: Overweight Trends

10. Ethnicity: Intake & Activity Trends

11. Ethnicity: Physical Activity (Exercising  20 min. on  3 days in previous week; 8 – 16 years old) (NHANES III, 1988-1994 – Crespo, 2001)

12. Disorders Linked to Childhood Obesity • Type II diabetes • Impaired glucose tolerance • Hyperlipidemia (LDL) • Negative self-image • Increased prevalence of adult obesity • Hypertension (SBP and/or DBP  95% • Cholecystitis in adolescence (50%) • Hepatic Steatosis • Sleep Apnea • Precocious Puberty (Dietz, 1998)

13. Rise in Cost of Hospitalization of Youth with Obesity-Associated Diseases (Wang, 2002)

14. Factors Contributing to the Epidemic

15. Periods with High-Risk, Excessive Weight Gain in Children • Infancy • Extent and duration of breastfeeding • Time of introduction of solids to diet • Extent of protein consumption • School-Age • Presence of television in child’s bedroom • Adolescence • Early puberty • Early menarche (Pediatrics, 2003)

16. Advertising Influences: • Toy and food companies cross promote their products. • Children’s positive associations with early childhood toys and educational products creates a strong bond from an early age. (Samuels, 2004)

17. TV ads are the primary medium forreaching children. Over 75% of food advertising budgets and 95% of fast food chain budgets are for TV. In 1997 major beverage companies spent $631 million for the promotion of drinks. The heaviest food advertising is targeted to young children. Children view an average of 2 – 3 hours TV/day. Children view an average of one food ad every 5 minutes of TV viewing time. Children view between 20,000 – 40,000 commercials per year. Media Influences: TV (Samuels, 2004)

18. Obesity and Television Viewing • Rate of obesity increases 2% for every 60 minutes of television content viewed per day • Average child watches 24 hours of television each week (Mayo Clinic, 2003)

19. Changes in Calories Per Serving1977 – 1996 (Nielsen, 2003)

20. 1960 2001 1 oz 6 oz 8 fl oz 32-64fl oz Portion Size: Intake Trends (Nicklas, 2001)

21. 700% larger 480% larger Typical Portion Size Compared to USDA and FDA Standards Recommended Typical (Young and Nestle 2002, 2003)

22. Families On-The-Go Contribute Nearly ½ of all family food expenditures were spent on food and beverages eaten outside the home, with ⅓ of the dollars spent on fast food. (Putnam, 1999)

23. Our Schools Contribute Too • 43% of elementary schools and 98% of senior high schools in America offer • School stores • Canteens • Snack bar • Vending machines (Weschler, 2001)

24. 1/2 of all public elementary schools schedule PE only 1-2 days/week. 1% of public elementary schools offer no PE *Schools with high poverty rates have lower averages in minutes of PE/week than other schools (Natl Cntr Ed Stats, 2006)

25. $9 billion spent each year for school breakfasts and lunches • Then students buy junk food, sugary beverages, etc. • 23% of public elementary schools reported one or more companies had contracts to sell drinks or foods at school. • These contracts often fund sports, extracurricular events, clubs, etc. (Narkin, 2005)

26. Cultural Influences: • Mothers cannot implement knowledge about healthy diet and activity without improved parenting skills. • They need the how more than the what. • “...to prepare chicken and vegetables – that has lots of vitamins... but when you work you don’t have time for it.”

27. Factors Contributing to Nebraska Childhood Obesity n=40,154 Nebraska students 234 schools (public/private) • Physical Activity More than ¾ students do not engage in adequate moderate or vigorous activity (involvement is decreasing since 1991) • Electronic Sedentary Behaviors HS students spend 3.65 hours in television (1 ¾ hours, video game systems (1/2 hour), computer (1 ¼ hours) use. *¾ students spend > 2 hours, ¼ students spend > 5 hours • Unhealthy Eating • Soda Consumption • 9/10 drank soda week before survey • 50% drank > 12 oz soda/day • 29.8 drank > 32 oz soda/day *Majority is regular soda, 2/3 soda drinkers only drank regular soda • Milk Consumption • 85% drank milk week before survey • 49.6% of these drank < 1 glass/day • 18.4% drank > 3 glasses/day • Fruit & Vegetable Consumption • 16.3% ate 5 servings/day • 61.3% ate < 2 servings/day

28. Interventions to Reduce Childhood Overweight Treatment: Interventions to Reduce Overweight Treatment Focus Treatment Format Dietary Interventions Child without Parents Versus Child with Family Physical Activity and Inactivity Individual Child Versus Group Format Behavioral Interventions Peer Modeling Weight Loss Surgery (ADAEVIDENCELIBRARY.COM)

29. Healthy Levels of Physical Fitness for Children • Active exertion 4 – 5 times per week • Energy expenditure at > 50 – 60% maximum • Play and activity (not exercise) (Samuels, 2004)

30. Raising Active Children • Turn off TV, Computer Games • Caregivers unite and get moving! • Promote P.E. in schools • Promote Activity…not exercise • Build a lifelong healthy activity routine Mayo Clinic, 2004)

31. Considerations for the Fitness Program • Age – gender – race • Sexual maturity, abilities • Reward systems • Family, socioeconomic status, environment • Access to convenient place to play • Sedentary activity time (Williams et al, 2002)

32. Hop, Skip, Jump, whatever…. Get Moving! US Dietary Guidelines for 6-11 years: 60 minutes activity/day • Examples of Community Awareness & Activity • Walk to School Day • Jump Rope for Heart • Hoops for Heart • Safe Routes to School

33. Meal Planning is the Key • Plan ahead • Day - week – month • Use the food pyramid guidelines • mypyramid.gov • Think convenience not fast food • Keep pantry and refrigerators stocked • You control the home food selections • Keep family involved in meal planning

34. Gatekeeper Theory • He/she who purchases the food for the family controls the consumption of the family. • If a child is given a choice between 3 healthy foods, he chooses healthy.

35. Students will consume fruits and vegetables if they are readily available • 2002 Fresh Fruit and Vegetable Program (free fresh fruit and vegetable snacks) • Funded by 2002 Farm Bill (Buzby, 2006)

36. American Academy of Pediatrics Advocacy • Help adults who influence youths to discuss health habits as part of weight control. • Enlist policymakers to support healthful lifestyle for children. • Encourage organizations to provide coverage for effective obesity prevention and treatment strategies. • Encourage public and private sources to direct research into strategies to funding toward preventing overweight and obesity and maximize limited family/community resources to achieve healthful outcomes. • Support and advocate for social marketing intended to promote healthful food choices and increased physical activity. (Committee on Nutrition, 2003)

37. Progress in Educational Intervention “Alliance for a Healthier Generation” May 2006: 87% of beverage industry and elementary/middle schools Agreement: Only sell: Water Unsweetened juice Lowfat milk Fat free milk

38. May 3, 2006 Beverage industry voluntarily eliminates sales of all drinks not 100% juice from elementary schools. Cadbury Schweppes, PepsiCo, Coca Cola and American Beverage Association agree to limit portion sizes and reduce calories available to elementary school children to 100 cal/container. This helps 34% of kids in 2006. Goal: expand to 75% of children by 2008-09 school year, expand to 100% of children by 2009-10 school year. (Natl Cntr Educ Stats, 2006)

39. Progress in Education Intervention “Alliance for a Healthier Generation” October 2006: Participants: Campbell Soup, Mars, Inc., Kraft Foods, Group Danone SA, Pepsico. Agreement: Guideline set for fat, sugar, sodium and calorie content for competitive foods in school vending, school stores, snack bars < 35%KCAL from fat < 10% saturated fat < 35% sugar by weight of product yet to be determined: sodium Washington Post, 2006

40. Family Physician Family NutritionEducationand/or Diet Behavioral Counseling Increased Physical Activity and/or Specialized Exercise Multidisciplinary Treatment of Childhood Obesity

41. Healthy Futures • A 12 week course where children and caregivers learn healthy principles in food selection, activity, and the relationship of emotions and food. • Criteria for Participation: • Referral by physician • Ages: 6-18 years • Successful completion of the bio-psychosocial assessment, if > age 10 • Family involvement: at least one caregiver commits to active participation • Weight status: at or above the 85th percentile for Body Mass Index (BMI) for age, gender • Child commitment: desire to learn and use new techniques to improve health

42. Strengths of Healthy Futures • Built-in communication with referring physician (minimum 3x/program) • Course length (12 weeks) promotes beginning of behavior changes • Program based on Shapedown®conducted by School of Medicine, University of California at San Francisco • Program director: certified in child and adolescent weight management training by American Dietetic Association and PhD in training and development. • Course providers complete 46 hours additional continuing education in childhood and adolescent obesity from school of medicine, University of California, San Francisco • On-site support services for referrals • On-going data collection, measuring success of program in: • Weight • Activity volume • Emotional variables • Communication

43. Key Program Components • 5th edition of curriculum • Child learns and brings information back to caregivers to practice together • Looking for future health-promoting behaviors – not just quick results • Promotes physical activity • Indoors • Outdoors • Imagine what can be done in home • Problem-solving practices

44. Family Obligations • At least one caregiver present and actively participating at each class • Child completes all homework assignments and actively participates at each class • Behaviors are practiced at home • Cost*: • $350 for first child • $250 for subsequent children in same family • Repeat classes if needed until comfort level achieved or advance to next level • Advanced Healthy Futures is a 20 week program. • Class reunions held quarterly *Grants and community-supported scholarships are being investigated. *Insurance plans with “wellness” components are receptive to payment.

45. Healthy Futures: Measures of Success • B.M.I.: height to weight comparison • Weight: change in percentile for age/gender • Nutrition Knowledge: food choices • portion control • label reading • Strength and stamina: ½ mile walk, mile walk • Stretch test • Step test • Activity: minutes of non-sedentary activity • Minutes of TV, computer, video games • Stress Management: worry wallets • substitutes for comfort/reward • Family Dynamics: minutes of family interacting time • use of …I feel, I need, Would you please? • meal planning techniques • portion control awareness

46. Healthy Future Statistics • Class One n=6 2/6 completed course on time • (ages 6-9) 5-female 1/6 completing course • 1-male 3/6 did not complete • Of the two (33%) who finished course: • Success in weight loss • Improved food choices • Increased strength • Increased stamina • Improved family dynamics • Improved self-esteem

47. Healthy Future Statistics • Class Two n=7 2/7 withdrew (parent availability) • (ages 10-13) 3-female 5/7 participating • 4-male • As of week 4: • 4/7 weight loss • 3/7 no weight loss • Marginal change in stamina • Improved food choices • Improved activity times • *official reassessment at week 6 (9-18-06) • Class Three begins October 30,2006 (ages 14-18)

48. Healthy Futures StatisticsBegan 1/8/07 Class Three n=7 1/7 withdrew (parent availability) (ages 12-16) 6-female 1-male Class Four n=7 All Participating (ages 6-11) 3-female 4-male

50. Questions?