1. Sarah Armstrong, MD Director, Healthy Lifestyles Program North Carolina School Community Health Alliance Conference December 14, 2009 The Childhood Obesity Epidemic: How we got here, what it means for a childs health, and what you can do

2. All Rights Reserved, Duke Medicine 2007 Name that Food ENRICHED FLOUR (WHEAT FLOUR, NIACINAMIDE, REDUCED IRON, THIAMIN MONONITRATE [VITAMIN B1], RIBOFLAVIN [VITAMIN B2], FOLIC ACID), CORN SYRUP, HIGH FRUCTOSE CORN SYRUP, DEXTROSE, VEGETABLE OIL (SOYBEAN, COTTONSEED AND HYDROGENATED COTTONSEED OIL WITH TBHQ AND CITRIC ACID FOR FRESHNESS), SUGAR, CRACKER MEAL, CONTAINS TWO PERCENT OR LESS OF WHEAT STARCH, SALT, DRIED STRAWBERRIES, DRIED APPLES, DRIED PEARS, CORNSTARCH, LEAVENING (BAKING SODA, SODIUM ACID PYROPHOSPHATE, MONOCALCIUM PHOSPHATE), CITRIC ACID, MILLED CORN, MODIFIED WHEAT STARCH, GELATIN, CARAMEL COLOR, PARTIALLY HYDROGENATED SOYBEAN AND/OR COTTONSEED OIL, MODIFIED CORN STARCH, XANTHAN GUM, SOY LECITHIN, COLOR ADDED, NIACINAMIDE, REDUCED IRON, RED #40, VITAMIN A PALMITATE, YELLOW #6, PYRIDOXINE HYDROCHLORIDE (VITAMIN B6), RIBOFLAVIN (VITAMIN B2), THIAMIN HYDROCHLORIDE (VITAMIN B1), FOLIC ACID, TURMERIC COLOR, BLUE #1.LESS THAN 0.5g TRANS FAT PER SERVING

3. All Rights Reserved, Duke Medicine 2007 600 calories per package (2 pop tarts) 38 grams of sugar No trans fat POP TARTS

4. All Rights Reserved, Duke Medicine 2007 Obesity Trends Worldwide

5. All Rights Reserved, Duke Medicine 2007 South East Asia & Pacific Region Nauru 78% Tonga 70% Samoa 63% Niue 46% French Polynesia 44% Africa Seychelles 28% South Africa 28% Ghana 20% Mauritania 19% Cameroon (urban) 14% South Central America Panama 36% Paraguay 36% Peru (urban) 23% Chile (urban) 23% Dominican Republic 18% North America USA 33% Barbados 31% Mexico 29% St Lucia 28% Bahamas 28% Eastern Mediterranean Jordan 60% Qatar 45% Saudi Arabia 44% Palestine 43% Lebanon 38% European Region Albania 36% Malta 35% Turkey 29% Slovakia 28% Czech Republic 26% % Obese 0-9.9% 10-14.9% 15-19.9% 20-24.9% 25-29.9% 30% Self Reported data

6. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1985 No Data <10% 10%–14%

7. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1986 No Data <10% 10%–14%

8. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1987 No Data <10% 10%–14%

9. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1988 No Data <10% 10%–14%

10. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1989 No Data <10% 10%–14%

11. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1990 No Data <10% 10%–14%

12. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1991 No Data <10% 10%–14% 15%–19%

13. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1992 No Data <10% 10%–14% 15%–19%

14. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1993 No Data <10% 10%–14% 15%–19%

15. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1994 No Data <10% 10%–14% 15%–19%

16. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1995 No Data <10% 10%–14% 15%–19%

17. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1996 No Data <10% 10%–14% 15%–19%

18. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1997 No Data <10% 10%–14% 15%–19% 20%

19. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1998 No Data <10% 10%–14% 15%–19% 20%

20. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 1999 No Data <10% 10%–14% 15%–19% 20%

21. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 2000 No Data <10% 10%–14% 15%–19% 20%

22. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 2001 No Data <10% 10%–14% 15%–19% 20%–24% 25%

23. All Rights Reserved, Duke Medicine 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25% Obesity Trends* Among U.S. Adults BRFSS, 2002

24. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 2003 No Data <10% 10%–14% 15%–19% 20%–24% 25%

25. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 2004 No Data <10% 10%–14% 15%–19% 20%–24% 25%

26. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 2005 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%

27. All Rights Reserved, Duke Medicine 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30% Obesity Trends* Among U.S. Adults BRFSS, 2006

28. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%

29. All Rights Reserved, Duke Medicine 2007 Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%

30. All Rights Reserved, Duke Medicine 2007 1999 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008 2008 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%

31. All Rights Reserved, Duke Medicine 2007

33. Turning the corner on childhood obesity…

34. All Rights Reserved, Duke Medicine 2007 03-04 N=2,159 03-04 N=981 0 5 10 15 20 25 1963-65 1966-70 1971-74 1976-80 1988-94 99-00 01-02 03-04 US 6-11 yr US 12-19 yr NHANES data sources: Ogden et al. Prevalence and Trends in Overweight Among US Children and Adolescents, 1999-2000. JAMA 2002;288(14):1728-1732. Ogden et al. Prevalence of Overweight and Obesity in the United States, 1999-2004. JAMA 2006;295(13):1549-1555. 19.0 19.5 20.0 20.5 21.0 21.5 22.0 2004200520062007 AR grades K-6 AR grades 7-12 The Arkansas Experiment: Act 1220 (2006)

35. All Rights Reserved, Duke Medicine 2007 ADULT BMI Weight (kg) / Height (cm) squared Between 18 and 25 is normal Between 25 and 30 is overweight Above 30 is obese http://heartline.in/images/diabetes_BMI_chart.gif

36. All Rights Reserved, Duke Medicine 2007 Pediatric BMI -same calculation -read as percentile -BMI correlates with risk for disease -shift paradigm from weight loss to weight maintenance

37. All Rights Reserved, Duke Medicine 2007 For example, a five year old girl with BMI of 20kg/m2 who maintains her weight but increases her height normally will get into the green zone by age 8. The same girl, if she gains weight slowly, and continues to gain height, will get into the green zone by age 10.

38. All Rights Reserved, Duke Medicine 2007

39. Source: Mokdad et al., Diabetes Care 2000;23:1278-83; J Am Med Assoc 2001;286:10. Diabetes Trends* Among Adults in the U.S 19901995 2001

40. All Rights Reserved, Duke Medicine 2007 Pre-Diabetes or Insulin Resistance Syndrome

41. All Rights Reserved, Duke Medicine 2007 Polycystic Ovarian Syndrome PCOS

42. All Rights Reserved, Duke Medicine 2007 Childhood Hypertension

43. All Rights Reserved, Duke Medicine 2007 Children and Cholesterol

44. All Rights Reserved, Duke Medicine 2007 Fatty Liver Disease Non-alcoholic steatohepatitis

45. All Rights Reserved, Duke Medicine 2007 Osteoarthritis Percent of total daily calories from soda, juice, and milk Neilsen SJ, Popkin BM. Changes in beerage intake between 1977 and 2001. American Journal of Preventive Medicine. 2004; 27(3):205-210.

46. All Rights Reserved, Duke Medicine 2007 Blounts Disease Pathologic tibia varum

47. All Rights Reserved, Duke Medicine 2007 Childhood depression Quality of life for obese children lower than that for children with cancer Bullying, teasing, social isolation and inability to participate in active or social events may contribute Rates of depression and anxiety are 2-3 times higher in obese adolescents than in normal weight teens. Reference: Barlow et al, Pediatrics (s): 2007

48. All Rights Reserved, Duke Medicine 2007 Economic Update Direct medical costs: >9% of all US health expenditures Estimated direct and indirect costs: $117 billion in 2000 now estimated at $130 billion per year Expenditures expected to increase as obese children become obese adults with chronic illnesses

49. All Rights Reserved, Duke Medicine 2007

50. PREVENTION, ASSESSMENT AND TREATMENT MESSAGE 5 fresh fruits/veggies a day 3 structured family meals 2 hours or less of screen time 1 hour of physical activity a day Almost none sugar-sweetened beverages

51. All Rights Reserved, Duke Medicine 2007 5 Fruits & Vegetables Goal 5 or more servings/day (1/2 cup = 1 serving) USDA recommends 9 servings/day. Why eat fruits and vegetables? Low in calories High in fiber (fiber goal: age + 5) Improve satiety Rich in vitamins and minerals Natural toothbrushes Model of Eating Competence: 1.No clean plate club rules 2.Parent feeding responsibility 3.Child feeding responsibility Ellyn Satter, Child of Mine

52. All Rights Reserved, Duke Medicine 2007 3 Structured Meals Family guidance: Eat at the table, at home, with the TV off. Offer a variety of foods-protein, grain, vegetable, fruit, and reduced fat milk or water – but no short order cooking! Create positive meal atmosphere Skipping breakfast is strongly associated with obesity. Eating breakfast is protective against developing obesity. Fruit and string cheese Granola bar and yogurt Cheese and crackers Peanut butter toast Cereal (<9g sugar) and milk Instant breakfast drink Barlow et al, Pediatrics, 2007

53. All Rights Reserved, Duke Medicine 2007 Creative Labeling Children Under 8 cannot distinguish commercials from reality No regulation on health claims on box, only Nutrition Label is regulated fortified with 8 essential vitamins and iron

54. All Rights Reserved, Duke Medicine 2007 Disney and Obesity

55. All Rights Reserved, Duke Medicine 2007 Healthy Plate American Diabetes Association American Cancer Institute

56. All Rights Reserved, Duke Medicine 2007 2 Hours or less of TV/media time Percent of 8-18 year-olds with each medium in their bedroom: Television Internet access VCR/DVD player Video game console 68% 20% 49% Cable/satellite TV Computer 37% 31% 20% 54% Premium cable channels Source: Kaiser Family Foundation, Generation M: Media in the Lives of 8-18 Year-Olds, March 2005: kff.org

57. All Rights Reserved, Duke Medicine 2007 TV Rules: Parents Role Percent of all 8-18 year-olds who say they have: TV rules that are enforced most of time 26% 53% 20% TV rules that are enforced some, a little or never some, a little or never No rules about TV Source: Kaiser Family Foundation, Generation M: Media in the Lives of 8-18 Year-Olds, March 2005: kff.org

58. All Rights Reserved, Duke Medicine 2007 Household Media Environment Percent of 8-18 year-olds living in homes where: TV is usually on during meals 63% 36% TV not usually left on during meals Source: Kaiser Family Foundation, Generation M: Media in the Lives of 8-18 Year-Olds, March 2005: kff.org

59. All Rights Reserved, Duke Medicine 2007 1: Or more hour of active time At least one hour of outdoor time per day associated with decreased rates of obesity and chronic illness National survey data indicate that 20% of US children 8 to 16 years of age reported 2 or fewer bouts of vigorous physical activity per week Decreased school activity time as compared with 10 years ago. Perceived neighborhood safety important determinant in childs outdoor play time. Built environment and access to safe play a critical concern. Anderson et al. Relationship of physical activity and television watching with body weight and level of fatness among children: results from the Third National Health andNutrition Examination Survey. JAMA. 1998;279:938–942

60. All Rights Reserved, Duke Medicine 2007 Almost none: Sweetened Beverages Liquid calories: 12 oz. soda= 150 calories 10 tsp sugar 12 oz. Kool Aid= 150 calories 10 tsp sugar Generally non-nutritive Replaces source of calcium- needs 500-1300 mg/day - Peak calcium needs in adolescence for bone density - Vitamin D Interferes with appetite for other healthful foods, especially in young children. Caffeine content-stimulant, restlessness, interferes with sleep

61. All Rights Reserved, Duke Medicine 2007 Fruit drinks/fruit punch Calories per 12 oz serving? –171 Teaspoons of sugar? –15 Overall 60% increase in the risk of becoming obese with each additional can of sugar sweetened drink consumed

62. All Rights Reserved, Duke Medicine 2007 What about 100% fruit juice? Recommendations 1.None for children under 1 2.Ages 1-7, 4-6 ounces/day 3.Ages 7 and up, no more than 12 ounces/day

63. All Rights Reserved, Duke Medicine 2007

64. Acceptance and Behavioral Control as Determinants of Parenting Style Parenting Style High AcceptanceLow Acceptance High ControlAuthoritativeAuthoritarian Low ControlIndulgentDisengaged Adapted from Chassin et al, J Pediatric Psychology 2005

65. All Rights Reserved, Duke Medicine 2007 Age-Appropriate Family Focus Breastfeeding Rules and structure Feeding responsibility Rules and structure Role modeling Support of teen Encouraging good peer influence Ellyn Satter, Child of Mine

66. All Rights Reserved, Duke Medicine 2007 CLINICAL CARE The Healthy Lifestyles Program RESEARCH EDUCATION ADVOCACY HEALTHY LIFESTYLES

67. All Rights Reserved, Duke Medicine 2007 Risk Reduction: BMI Stabilization 10 15 20 25 30 35 -12-606 Time, months Healthy Lifestyles BMI, kg/m 2 N=10; random cohort sample

68. All Rights Reserved, Duke Medicine 2007 Risk Reduction: BMI in Cohort Number of Patients

69. All Rights Reserved, Duke Medicine 2007 Body Fat Percent Percentile

70. All Rights Reserved, Duke Medicine 2007 Initial Cohort Results Variable*InitialLast Weight (kg)74.976.2 BMI32.532.2 Z-score5.25.1 Co-Morbidities3.82.4 * Mean Values Mean time from initial to last visit was 7.4 months

71. All Rights Reserved, Duke Medicine 2007 Changes in Blood Pressure: Cohort Patients Blood PressureInitial VisitLast Visit Normal1120 Pre-hypertension55 Stage 1 Hypertension87 Stage 2 Hypertension102 Total34

72. All Rights Reserved, Duke Medicine 2007 Pediatric and Adolescent Lifestyle Survey Results: Cohort Patients

73. All Rights Reserved, Duke Medicine 2007 Mood and Feeling Questionnaire: Cohort Patients Score of 10 or greater indicates depression. 8 patients had an initial score of 10 or greater –6 (75%) of these patients score returned to normal –No patient with an initial score 10 at last visit

74. All Rights Reserved, Duke Medicine 2007

75. http://www.eatsmartmovemorenc.com/ http://pediatrics.duke.edu/modules/ctr_ped_cendo_sv c/index.php?id=1http://pediatrics.duke.edu/modules/ctr_ped_cendo_sv c/index.php?id=1 http://kidshealth.org/ http://www.bam.gov/ http://win.niddk.nih.gov/publications/child.htm Resources

76. Thank you Sarah Armstrong Director, Healthy Lifestyles Duke Childrens Primary Care December 14, 2009