1. kp.org/communitybenefit The Weight of the Nation is Out of Control and We Can Change That Sandra Hoyt Stenmark M.D. May 2013

2. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Disclosures School-Based Health Center: Conference: Strengthening the Core Speaker: Sandra Hoyt Stenmark M.D. Physician Lead for Pediatric Cardiovascular Health at Kaiser Permanente in Colorado Date: May 2013 Disclosures: NONE

3. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together WHO definition of Health Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

4. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Objectives 1. Identify health and economic consequences of obesity 2. Analyze factors contributing to obesity and poor cardiovascular health 3. Construct interventions which will decrease obesity and improve cardiovascular health

5. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Many Factors Drive and Shape Health Family History and Genetics 30% Environmental and Social Factors 20% Personal Behaviors 40% Medical Care 10% Drivers of Health 5 Source: McGinnis et al, Health Affairs, 2002

6. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together 6 The Social Ecological Framework Neighborhood / Community Society Individual / Family Home / School / Worksite Physical and Mental Health “Body, Mind and Spirit”

7. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Childhood Overweight and Obesity On average, between 2010 and 2011, 28 percent of all Colorado children ages 2 to 14 were overweight or obese, up from 26 percent in 2008-2010. Source: CDPHE: Health Statistics Section. 2010-2011 Child Health Surveys.

8. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Obesity Prevalence Colorado Children 2-14 years 2008-10 Colorado Department of Health and Environment- Child Health Survey

9. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Prevalence of Food Insecurity and Obesity in Colorado Children Health Statistics CDPHE, Child Health Survey 2010

10. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together More than one in six Colorado kids lived in poverty in 2011. 3% Children Living in Poverty since 2010 Source: U.S. Census Bureau. 2000 and 2001 Supplemental Surveys, 2002-2011 American Community Surveys.

11. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Effects of childhood obesity Increased rates of premature death in adults -NEJM 2010;362:485-93 Adverse levels of lipids, insulin and blood pressure - Pediatrics 1999;103:1175-82 Fatty streaks and lesions in coronary arteries in young adults - NEJM 1998;338:1650-6 Fatty liver and liver fibrosis in children - J Ped 2003;143:500-5

12. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Emotional and social impacts of childhood obesity Weight bias begins in preschool Higher BMI -more frequent and intense victimization Source of bias: peers, teachers, parents Impacts: poor self esteem, depression, less likely to be chosen as friend, increased suicidal ideation -Puhl, Psychological Bulletin 2007, Vol 133, No 4, 557-80

13. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Obesity is Expensive Annual Medical costs of obesity United States $147 billion Colorado $874 million www.cdc.gov/obesity/causes/economics.html United States medical costs + loss of productivity costs Overweight- $72 billion Obese- $198 billion Source: 2010 Society of Actuaries: Obesity and its Relation to Mortality and Morbidity Costs

14. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Case I 5 yo Ethiopian male with BMI 99.1% in for CPE How do you bring up weight? How do you engage patient and parent? What evidenced based family behaviors are important to address?

15. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Messaging and motivating behavior change Lack of awareness re weight status When parents made aware they are more motivated to action livewellcolorado.org /

16. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Messaging which engaged Hispanic families “Too much weight for his health” “Demasiado peso para su salud”

17. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together KPCO RD Intervention # 3 phone visits and 1 in person visit 9/2012-1/2013 Topics addressed: daily active play fruit & vegetable intake sugared beverages portions healthy snacks

18. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together 5-2-1-0 Modifiable Behaviors

19. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Colorado Children’s Daily Behaviors 2010-2011 http://www.chd.dphe.state.co.us/Resources/cms/hs/yrbs/ChildHealth Categories.html

20. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Five servings of vegetables and fruits/day

21. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Two Hours or Less of Screen Time/ Day GENERATION M2: Media in the Lives of 8- to 18-Year-Olds Kaiser Family Foundation Report 2010

22. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together One Hour or More of Daily Physical Activity Improves: mood, cognition, fitness, bone strength, sleep quality Lowers risk of: diabetes, heart disease, obesity, anxiety, depression, stress, colon & breast cancers www.health.gov/paguidelines

23. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Time Outdoors Increases Physical Activity Burdette Arch Pediatr Adol Med 2004;159:46-50. Cleland V, et al. Int J Obesity 2008;32:1685-93.

24. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Zero Sugared Beverages Sugared beverages account for nearly half of all added sugar consumption in the average American diet. Dietary Guidelines of America 2010

25. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Other Obesity Interventions Portion size Breakfast Diet quality Food Insecurity Sleep Family meals Eating out/ Take out

26. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together KPCO RD intervention results

27. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Case II 11 yo Hispanic male with BMI 99%, persistent asthma presents at CPE Neighborhood without safe places to play or walk and no easy access to fruits and vegetables. How do you engage family? What resources would you consider?

28. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together

29. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Barriers to Walking-Photovoices

30. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together

31. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Case II Mom discussed barriers during first 2 phone visits On 3 rd phone visit ready to goal set: physical activity sugared beverages

32. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Community Resources Fire up Your Feet http://fireupyourfeet.org/ Outdoor Resources http://www.getoutdoorscolorado.org/ Boys and Girls Clubs http://www.bgca.org Let’s Move letsmove.gov

33. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Safe Routes to School Reduces Injury The annual rate of school aged pedestrian injury during school-travel hours decreased 44% in census tracts with SRTS interventions. http://www.saferoutespartnership.org/ Pediatrics 2013;131:290–296

34. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Strengthen Schools as the Heart of Health. http://thrivingschools.kaiserpermanente.org/ www.letsmove.gov Accelerating Progress in Obesity Prevention- IOM May 2012

35. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Community Weight Loss Resources Kaiser Permanente Resources www.kphealthyme.com MEND Http://us.mendcentral.org/ Por Tu Familia http://www.diabetes.org/in-my-community/local- offices/denver-colorado/por-tu-familia-colorado.html Weigh and Win for Adults www.weighandwin.com/

36. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Case III 15 yo female presents with BMI of 99% and the following growth chart How do you engage patient and family? Next steps?

37. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Case IV What questions would you ask if you saw this child between ages of 10-16 years? What interventions took place when he was 16 yo?

38. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together A Colorado Solution for Hunger Hunger Free Hotline

39. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Case V 10 yo male with BMI 99% Mom concerned because he is being teased about his weight Engage? Next Steps? Resources?

40. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Bullying Prevention http://www.stopbullying.gov Encourage kids to speak to a trusted adult Encourage friendships and hobbies Website with tips and strategies for staying safe and stopping bullying Promote an environment in which all individuals are treated with respect

41. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together KPCO School Initiatives State Legislation: Hunger assistance Breakfast after the bell Beverage Standards Physical Activity Standards Complete Streets Grants: Live Well Communities Fire Up Your Feet Thriving Schools National Safe Routes to School Playworks KP Educational Theater Program

42. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together We Can Fix It School based health centers have an important role in identifying, preventing and treating obesity School policies, programs and environments can promote health Engaging students, parents, school officials and community members will increase success

43. kp.org/communitybenefit WE BUILD A BRIGHTER FUTURE together Thank you Sandra.H.Stenmark@kp.org