Promoting Community-based Obesity Prevention Obesity is an epidemic and is one of the most important health problems Texas faces today. Obesity is a disease whose prevalence is growing rapidly. It must be considered a disease because it is accompanied by costly medical problems.

US Surgeon General David Satcher, MD, PhD Surgeon General’s Call to Action to Prevent & Decrease Overweight & Obesity “Overweight and obesity may soon cause as much preventable disease and death as cigarette smoking. People tend to think of overweight and obesity as strictly a personal matter, but there is much that communities can and should do to address these problems.” US Surgeon General David Satcher, MD, PhD In his report entitled “The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity,” US Surgeon General David Satcher outlined strategies that communities can use un helping to address the problems.

Surgeon General’s Call to Action to Prevent & Decrease Overweight & Obesity “Communities can help when it comes to health promotion and disease prevention. When there are no safe places for children to play, or for adults to walk, jog, or ride a bike, that’s a community responsibility. When school lunchrooms or workplace cafeterias don’t offer healthy and appealing food choices, that is a community responsibility. And when we don’t require daily physical education in our schools, that is also a community responsibility.”

Building Healthier Communities By community, we mean a group of people who share a common place, experience, or interest. Such as those in the same town, ethnic and/or religious community. Community health refers to the well-being of everyone in a community. It asks the question, “How healthy are all of the children of the community? Older adults? The poor? Collaborative partnerships are alliances that are used to improve the health of a community. They encourage people to get involved and make a difference. Most of us want the same things from our communities. We want them to be safe from violence and illness; we want neighborhoods alive and that work well. And we would all like to have people who care for us and whom we trust. But how do we develop a community like that? It is our belief that communities are built when people work together on things that matter to them. Lets start with some definitions.

Who Should Be Involved? For example, a community partnership to promote child health might include representatives from: The media The business community Area schools Civic and community organizations Youth organizations Local government Health organizations The Faith community Financial institutions When developing these collaborative partnerships, who should be involved? First, it’s important that the collaboration is as open as possible. This means individuals from the different parts of the community as well as different levels. People from each of these areas will be able to promote child health in important unique ways. By working together, a very strong partnership will exist in the community.

You are an important collaborative partner in Obesity Prevention! In a healthy community, working together for the good of the community is a constant part of everyone’s lives.

What is Obesity? Obesity - having a very high amount of body fat in relation to lean body mass, or in adults, a Body Mass Index (BMI) of 30 or higher. Overweight - increased body weight in relation to height, when compared to some standard (BMI over 25). Body Mass Index (BMI) - a measure of weight in relation to height. Obesity is an excessively high amount of body fat or adipose tissue in relation to lean body mass Overweight is an increased body weight in relation to height, when compared to some standard of acceptable or desirable weights BMI is an anthropometric index of weight & height BMI is a screening tool to identify individuals who are underweight or overweight

What is BMI? A screening tool to identify: Overweight At risk for overweight Underweight BMI-for-Age in children correlates with health risks in adulthood Elevated insulin levels Cardiovascular disease High blood pressure

Calculate your BMI To calculate your body mass index (BMI) Multiply your weight (in pounds) by 700 and divide by your height (in inches) squared (Weight x 700/height2) Other risk factors: A BMI of 20-25 is associated with the lowest health risk.

BMI Categories for Adults BMI Categories for Adults At a BMI You are considered: Below 18.5 Underweight 18.5 to 24.9 Normal 25 to 29.9 Overweight 30 to 34.9 Mildly obese 35 to 39.9 Moderately obese 40 and above Extremely obese What is overweight? Here are the BMI categories for adults. What do they mean? If you are 5’6”, you need to weigh 154 to be overweight (BMI = 25). To be obese, you need to weigh 185 lbs (BMI = 30). Source: NIH Evidence Report on Overweight & Obesity, 1998

Overweight in Children in Texas Overweight – Body Mass Index equal to or greater than the 95th percentile is overweight in standard reference tables based on age and gender Norms for BMI: NCHS/CDC, http://www.cdc.gov/growthcharts/

For Children, BMI Differs by Age Boys: 2 to 20 years Example: 95th Percentile Tracking Age BMI 2 yrs 19.3 4 yrs 17.8 9 yrs 21.0 13 yrs 25.1 http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm Because adiposity varies with age and gender, BMI must be age and gender specific. As illustrated here, growth has been established along the 95th percentile with BMI-for-age reaching a minimum at 4 years of age and then increasing. From age 6 to 19 years, values of BMI-for-age for females exceed those for males. BMI BMI Source: CDC Growth Chart Slides

What does the 95th percentile look like? For a girl: 4th grade, 9 ½ years old, 48 inches (4’) 85th percentile = 64 lbs. 95th percentile = 73 lbs. 8th grade, 13 ½ years old, 60 inches (5’) 85th percentile = 118 lbs. 95th percentile = 137 lbs. 11th grade, 16 ½ years old, 66 inches (5’ 6”) 85th percentile = 154 lbs. 95th percentile = 181 lbs.

Causes of Obesity Genetic Factors Environmental Factors Psychological factors Other causes Genetic, environmental, psychological and other factors all may play a role in obesity. Which occurs when a person’s calorie intake exceeds the amount of energy he or she burns. Obesity tends to run in families, but since family members share diet and lifestyle habits as well as genes, identifying genetics as the sole cause may be difficult. Many people genetically predisposed to obesity do not become obese or manage to lose the weight and keep it off. Environmental factors include lifestyle behaviors, such as diet and activity levels. Many people eat in response to negative emotions, such as boredom, sadness or anger. Most overweight people have no more psychological disturbance than normal weight people, but about 30% of people seeking treatment for serious weight problems nave trouble with binge eating. Binge eaters consume large amounts of food while feeling they can’t control how much they are eating. Some illnesses can lead to overeating as well as certain drugs may cause excessive weight gain. These other causes are believed to be responsible for only about 1% of all obesity cases.

Some facts about the health status of adults and children in the U.S. Before we discuss the basics of promoting healthy eating through school food service, let’s review some research on the health status of kids in the U.S. today.

Trends in Adult Obesity in Texas Between 1990 and 2002, the prevalence of overweight and obesity in Texas adults rose from 42.9% to 63% In Texas, obesity is more pronounced among low-income adults, while overweight is more prevalent among high-income adults.

Adult Trends - The Facts Obesity is highest among African Americans (42%) and Hispanics (30%) Prevalence of obesity and overweight combined in Texas is higher among men (69%) than women (55%) and among people 45-64 years of age (70%)

Recently, Houston was proclaimed the “fattest city” in the US for the 2nd year running. Although this wasn’t a true obesity prevalence study, it did examine factors that contribute to the increase in obesity, and we have a lot of environmental barriers to overcome.

If you look at the fine print, you’ll see that it isn’t just Houston that ranks high as a “fat city”. Texas has 4 cities in the top 10 on this list (Houston, Dallas, San Antonio, Fort Worth)—more than any other state.

Percentage of all deaths Actual Causes of Death, 2000 Tobacco 435,000 * Poor diet/Lack of exercise 400,000 Alcohol 85,000 Infectious Agents 75,000 Pollutants/Toxins 55,000 * number of deaths Motor Vehicles Crashes 43,000 Firearms 29,000 Sexual Behavior 20,000 Illicit Drug Use 17,000 Percentage of all deaths Source: Mokdad AH, Marks JS, Stroup DF, and Gerberding JL. Actual Causes of death in the United States, 2000. (JAMA 2004;291:1238-45)

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%

Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% 15%–19% ≥20

Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% 15%–19% ≥20

Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% 15%–19% ≥20

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

Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults BRFSS, 2002 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% Source: Behavioral Risk Factor Surveillance System, CDC

School-aged Children Trends Nationally the prevalence of overweight and obesity has doubled in the last 20 years and is highest among minorities and males. SPAN study indicates that the prevalence of child and adolescent overweight may be increasing at a rate similar to that of the adult population!

Prevalence of Overweight in Texas School Children Combined male and female findings by grade: 4th grade – 22.4% 8th grade – 19.2% 11th grade – 15.5% TDH Innovation Grant, University of Texas Health Science Center – School of Public Health – Houston

Prevalence of Overweight in Texas School Children Overweight prevalence highest among: Hispanic boys 29.5%-32.6% 4th grade Hispanic girls 26.7% 4th grade African American girls 30.8% 8th grade African American girls 23.1% Overweight prevalence lowest among: 11th grade White/other girls 5.5% TDH Innovation Grant, University of Texas Health Science Center – School of Public Health – Houston

Map of Public Health Regions in Texas Just to refresh your memory, here is a pictorial representation of the PHR’s in Texas.

11th Grade Prevalence of Overweight 11th Grade Prevalence of Overweight* by Public Health Region in Texas, 2000-2002 *Overweight is > 95th Percentile for BMI by Age/Sex

8th Grade Prevalence of Overweight 8th Grade Prevalence of Overweight* by Public Health Region in Texas, 2000-2002 *Overweight is > 95th Percentile for BMI by Age/Sex

4th Grade Prevalence of Overweight 4th Grade Prevalence of Overweight* by Public Health Region in Texas, 2000-2002 *Overweight is > 95th Percentile for BMI by Age/Sex

ODDS RATIOS FOR OBESITY IN YOUNG ADULTHOOD 3-5 6-9 10-14 15-17 1-2 AGE OF ONSET OF OBESITY Whitaker, NEJM, 97

The Harsh Reality One Texas school-aged child out of three is overweight or obese. CDC projected that the lifetime risk of developing diabetes for children born in 2000 was more than 30% for males and 40% for females. A child who is overweight at age 12 has a 75% chance of being overweight as an adult. Two out of three Texas adults are overweight or obese. In 2001, one out of every 200 Texans went to the hospital because of a problem linked to being overweight or obese.

Increased Cost Burden $117 billion spent in 2001 according to Surgeon General report A significant portion of the increased costs of obesity are passed on to the American public adding an average of $732 to the mean yearly medical bills of all Americans.

The Cost of Adult Overweight & Obesity in Texas Estimated $10.4 billion in 2001 Includes $4.2 billion for health care An additional $6.2 billion impact from lost productivity due to illness, disability, and premature death. Total cost estimates range in value from $8.8 billion to $14.2 billion, depending on the underlying assumptions. Texas Dept. of Health - Preliminary Analysis, Jan. 2004

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.

Health Consequences of Obesity for Children Depression/low self-esteem Asthma High blood pressure Type 2 diabetes Sleep apnea Progression to adult obesity Other disorders (i.e. PCOS, fatty liver)

Most Logical Approach is PREVENTION

Health Benefits of Obesity Prevention for the General Population Reduced development of chronic diseases Improved nutrition reducing gastro-intestinal problems and osteoporosis as well as CVD, diabetes and cancer Improved fitness Improved academic performance

Best prevention approach is: TARGET CHILDREN and THEIR FAMILIES In preventing obesity, the most logical group to start with is children, since childhood obesity is a precursor of adult obesity.

Levels of the Spectrum of Prevention Influence policy and legislation Change organizational practices Foster coalitions and networks Educate providers Promote community education Strengthen individual knowledge and skills Children & Weight What Communities Can Do University of California Agriculture and Natural Resources

Levels of the Spectrum of Prevention Sample specific goal: To decrease soft drink consumption during the school day and at school-sponsored events Children & Weight What Communities Can Do University of California Agriculture and Natural Resources

Spectrum Level 1: Strengthen individual knowledge and skills (to decrease soft drink consumption) Strategies: Teach students about health consequences associated with soft drink consumption such as cavities, broken bones, and overweight. Teach students media literacy to understand how advertising influences behavior. Children & Weight What Communities Can Do University of California Agriculture and Natural Resources

Promote community education Spectrum Level 2: Promote community education (to decrease soft drink consumption) Strategy: Publish articles on healthy beverage choices in school newspapers, PTA newsletters, local newspapers and other community publications. Children & Weight What Communities Can Do University of California Agriculture and Natural Resources

Spectrum Level 3: Educate providers (to decrease soft drink consumption) Strategies: Encourage adults to offer water, milk and fruit juice (instead of soft drinks) at meetings, parties, and other school-sponsored events. Encourage adults to be role models by drinking water, milk and fruit juice (instead of soft drinks) and encouraging children and teens to do the same. Children & Weight What Communities Can Do University of California Agriculture and Natural Resources

Fostering coalitions and networks Spectrum Level 4: Fostering coalitions and networks (to decrease soft drink consumption) Strategy: Convene a coalition on children and weight. Children & Weight What Communities Can Do University of California Agriculture and Natural Resources

Change organizational practices Spectrum Level 5: Change organizational practices (to decrease soft drink consumption) Strategies: Limit access to vending machines by only turning them on after school hours. Add healthy alternatives such as milk, bottled water, and juice to vending machines. Children & Weight What Communities Can Do University of California Agriculture and Natural Resources

NO SOFT DRINK CONTRACTS Spectrum Level 6: Influence policy and legislation (to decrease soft drink consumption) Strategies: Encourage school districts to reject soft drink contracts. Advocate for a statewide policy to ban soft drink contracts in schools. NO SOFT DRINK CONTRACTS Children & Weight What Communities Can Do University of California Agriculture and Natural Resources

based on what you think is important and the resources you have. Where do you start? ? With your priorities... based on what you think is important and the resources you have. Children & Weight What Communities Can Do University of California Agriculture and Natural Resources

Four Goals of the Strategic Plan for the Prevention of Obesity in Texas Build awareness of the problem Mobilize families, schools, & communities Advocate for a supportive environment Monitor progress

CDC Grant-Funded Initiatives Expand Strategic Plan into a comprehensive plan with 5 pillars TV viewing Breastfeeding 5 A Day Caloric imbalance Physical activity

Strategic Plan for the Prevention of Obesity in Texas is intended as a SPRINGBOARD for ACTION

Thought for the Day If an answer to this obesity epidemic is not found soon, for the first time in at least a century, the present generation of children will not live as long as their parents.