1. University of Maryland School of Medicine Mini-Med School 2012 CHILDHOOD OBESITY EPIDEMIC Jay A. Perman, MD President University of Maryland, Baltimore Elsie Stines, MS, CPNP Pediatric Nurse Practitioner Project Director, President’s Office

2. POINTS TO BE COVERED • Overview of Childhood Overweight/Obesity Epidemic • Medical Complications • Causes of Childhood Obesity • Call to Action-The Role of Healthcare Professionals • Nutritional Recommendation

3. Definition of Obesity • At risk for obesity is: • BMI-for-age & gender from 85th to 95th percentiles • Obesity is: • BMI-for-age & gender ≥ 95th percentile • 30% of U.S. children and adolescents are at risk or obese [NHANES, USDHHS 2004]

5. BODY MASS INDEX • BMI is the most effective tool for the assessment of overweight and obesity in children • BMI provides a guideline for weight in relation to height BMIFormula weight (kg) / [height (m)]2 or Weight in pounds x 703/height in inches2 Must plot on CDC growth chart!

12. Exception to BMI Metric:Use Waist Circumference • If BMI > 85th % and child does not appear obese-waist circumference at the umbilicus can be obtained. • Age 6-12 years: Waist circumference >61 cm or 24 inches (probably overweight) • If pubertal: Waist circumference > 95 cm or 37.5 inches (probably overweight) [Pediatrics 2005; 115 1623-1630]

13. Epidemic of Overweight in Children

14. Prevalence of Overweight by Race/Ethnicity (Aged 12-19 years) [ CDC.gov] Adolescent Boys AdolescentGirls

15. Obesity and Socioeconomic Status in Children and Adolescents

16. Medical Complications

17. Common Medical Consequences of Overweight • Hyperlipidemia - Elevated levels of cholesterol • Glucose Intolerance - Type 2 Diabetes • NAFLD - Nonalcoholic fatty liver disorder • NASH - Nonalcoholic steatohepatitis (fatty liver disease) • Cholelithiasis - Gallstone • Hypertension - High blood pressure

18. Psychological Complications of Childhood Obesity • Lower self esteem • Depression • Loneliness • Teased by peers • Bullying • Absenteeism • High-risk behaviors • Oppositional-defiant disorder

19. Socioeconomic Consequences of Obesity • Fewer years of advanced education • Lower family income • Higher poverty rates • Lower wages • Lower marriage rates • Less likely to be hired

20. Contributing Factors to Obesity • Genetics • Behavior • Exercise • Diet • Environment

21. Genetics

22. Genetics • Heredity may influence fatness and regional fat distribution • Rare genetic syndromes may co-exist with obesity • Heredity may co-exist with environmental factors • Parental modeling of both eating and • exercising behaviors • Both parents obese

23. Behaviors • Low-energy Expenditure • Watching TV or playing video games • High-calorie snacks when watching TV • Diet • Regular consumption of high calorie foods, vending machine snacks, soft drinks • Psychological Factors • Overeating to cope with problems or to deal with emotions • Family/Social Factors • Parents purchasing unhealthy foods

24. Environment • Built Environment • Sidewalks • Parks • Food Deserts • School Bus • Safety

25. What Can We Do? • Carefully avoid a blaming approach • Understand and acknowledge role of genetics • Some individuals gain weight more easily • Better to use words like “unhealthy weight” or “weight problem”

26. Focus on health and function rather than appearance • Growing into a healthy body weight instead of an ideal weight • Choosing a target weight is often unrealistic and leads to discouragement

27. Behavioral Change Model • Self monitoring of target behaviors • Log of food • Log of activity • Stimulus Control • Reducing access to unhealthy behavior such as juices and sodas or removing a television from bedroom • Making fruits and vegetables more accessible

28. Behavioral Change Model • Goal setting • SMART • Specific • Measurable • Attainable • Realistic • Timely • Contracting • Positive Reinforcement • Negotiated by parent and child • Rewards should be small activities or privileges; food should not be used as reward

29. Family Centered Communication • Behavior change should be collaborative rather than prescriptive • Child should be directly involved in decision making

30. Motivational Interviewing • Encourage patients to identify reason for behavior change, including their solutions • Tone should be nonjudgmental, empathetic and encouraging. • Goals should be achievable • Select a few specific behaviors related to weight management • Avoid Scare Tactics

31. Activity Assessment • Home • TV in bedroom, access to free play, organized sports • School • Physical education, affordability of activities, safety concerns • Lifestyle Activity

32. Activity • Emphasize activity, not exercise - 60 minutes daily • Vary the activity • Find activity child likes • Encourage organized sports or structured sports • Encourage activities done as a family

33. Nutritional Assessment • Frequency of eating out • Intake of calorie-containing beverages • Frequency and portion size of energy dense foods (cookies, chips, ice cream) • Servings of vegetables and fruits • Number of meals and skipped meals • Typical snacking patterns • School lunch-purchased or brought from home

34. Dietary Strategies for Families • Balance calories with activity to maintain growth • 60 minutes of play or physical activity daily • Fruits and veggies daily • Limit juice and sugar sweetened beverages • Change to skim milk • Eat whole grain breads and cereals

35. Dietary Strategies for Families • Reduce salt intake, including processed foods • Eat lean meats • Eat more fish • Substitute tofu and beans for meat • Use vegetable oil or soft margarines in cooking • Limit high calorie sauces, e.g. Alfredo

36. Family Factors • Shopping habits - coupons, meal planning, grocery list, reading labels, grains • Frequency of family meals • Family style or served by parent • Meal location • Television

37. Public Policy Approaches • Walking school buses • Demand all food in school meet US Dept. of Agriculture nutrition guidelines • Daily physical education in school • Campaign for sidewalks, playgrounds, bike paths and recreational facilities, particularly in underserved areas • Eliminate unhealthy advertisements • Advocate breastfeeding

38. Prevention • Early recognition • Teach healthy behaviors at young age • Create a healthy eating environment • Create an active environment • Make physical fitness fun • One change at a time • Families and schools are the two critical links

39. Resources • Myplate.gov • Fruitsandveggiesmatter.org • We Can • cdc.gov website

42. An Ounce of Prevention is Better than a Pound of Cure