NH Childhood Obesity Project

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NH Childhood Obesity Project

• Shawn V. LaFrance, MS, MPH
• Foundation for Healthy Communities
• Changing the Scene Conference March 23, 2007

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Foundation for Healthy Communities

• Mission improve health and health care in New
  Hampshire
• Quality of care
• Access to care
• Community health
• Partnerships include hospitals, clinicians,
  health plans, home care agencies, public policy
  officials, etc.

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The Problem Related Conditions

• Type 2 Diabetes
• Atherosclerosis
• High Cholesterol
• Sleep Apnea
• Fatty Liver disease

• High Blood Pressure
• Depression
• Gallbladder disorders
• Skeletal disorders
• Eating disorders

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NH Childhood Obesity Survey

• Objective Document the prevalence of childhood
  obesity among children ages 6-12 yrs old
• Approach Convenience sample from 25 primary care
  sites statewide
• 1,453 medical records

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NH Childhood Obesity Survey

• Methodology
• 50/50 split x gender
• 65 records/practice
• 6-9 yrs 35 and 10-12 yrs 30
• well child visits in 2005
• 2 yrs in the practice

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Defining Obesity

• BMI kg/m2 wt in lbs/ ht² in inches x 703
  (calculate and plot on chart)
• Terminology is not standardized
• AAP and CDC recommends
• 85-95 at risk for overweight
• 95 overweight
• Many (including the American Obesity Assoc.) use
  BMI 85 - 95 overweight and BMI95 obese

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Prevalence
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Prevalence
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Insurance Status
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Documented Diagnosis
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Documented Diagnosis
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Practice Location
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Physical Activity
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Diet
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Other Assessments
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An epidemic

• 2003-2004 NHANES 17.1 of US children (6-19 yo)
  are obese with BMI 95.
• Obesity increased from 13.8 to 16 in girls and
  from 14 to 18.2 in boys since the 1999-2002
  survey.
• 37 of children (ages 6-11yo) and 34 of teens
  (ages 12-19) are overweight (BMI of 85-95).

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Do obese kids obese adults?

• Chance of obese child becoming obese adult
  increases from 20 at age 4 to 80 by
  adolescence.
• Obese adults who were obese as children have
  higher BMIs than obese adults who were normal
  weight as children.
• Whitaker et al NEJM. 1997337869-873
• Schwarzndberg S, MinnMed. 200562-66

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Costs of Obesity

• Annual hospital costs related to childhood
  obesity rose from 35 million in 1979-1981 to
  127 million from 1997-1999
• The number of days spent in the hospital doubled
  during that same time period.
• CDC National Hospital Discharge Survey (NHDS)

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Root Causes of Obesity

• American Heart Association (July 2006) issued
  Scientific Statement on Diet and Lifestyle. This
  document identified large portions and
  inexpensive fast foods as major causative factors
  in our current obesity epidemic.
• Circulation July 2006

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FRENCH FRIES
20 Years Ago
Today
210 Calories 2.4 ounces
610 Calories 6.9 ounces
How many calories are in these fries?
Calorie Difference 400 Calories
How to burn 400 calories   Walk 2 hr 20 Minutes
Based on 130 pound person
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Television

• Incidence of obesity is highest in children
  watching TV4 hours/day
• Incidence of obesity is lowest in children
  watching TV
• Kids watch 1,023 hrs/yr (Neilsen 2000)
• Rate of obesity 8X greater if a child watchs TV
  5hrs/d
• 25 American kids watch 4hrs/d
• TV in bedroom increases odds of overweight by
  additional 31 for every hour watched
• 57 of children 8-16 have TV in BR
• Dennison et al. Pediatrics 20021091028-1035,
  Ridout et al. Henry J Kaiser Family
  Foundation. 2003 Pediatrics 2003
  112(2)424-430, Crespo et alArch Ped Adol Med,
  155360-365

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Diet-restaurants

• Increased eating out from 16 to 29 from
  1977-1995
• By mid 1990s Americans eating 23 meals/month out
  with 8 of 23 from fast food restaurants
• USDA survey in 1995 showed school age kids get
  40 of calories out of home.
• USDA data from NCFS 1977-78 and CSFII 1994-95

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Environment Matters

• American Heart Association notes that the
  environment has a powerful influence on whether
  people consume excess calories and follow a
  healthy diet.
• Walking has decreased by 40 in adults and by 60
  in children since 1977
• Decreased playing outside due to increased
  traffic and crime.
• Innovations lead to decreased activity
• Remotes, garage door openers, escalators
• Convenience foods
• US Dept Transportation Bureau of Transportation
  Statistics, JNHTS 2001 Highlights report,
  BTS03-03

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Recommendations from the New Hampshire Childhood
Obesity Expert Panel
Preventing Childhood Obesity Promoting
physical activity healthy eating
April 2007
Beth Gustafson Wheeler, MS Changing the Scene
Conference March 23, 2007
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NH Childhood Obesity Expert Panel

• Convened September 2007
• Purpose Develop practical recommendations
  for NH communities.
• National reports and recommendations
• Evidence-based and promising practices
• Panel Multiple disciplines represented
• Release date April 2007

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Panel Members
Chuck Cappetta, MD NH Pediatric Society Madeline
Dalton, PhD Hood Center for Children and
Families, Dartmouth Medical School Joe
Drake Plus Time NH Amy Dumont, RN NH Heart
Association and St Joseph Hospital Merrill
Friedman, MA, LCMHC Slatoff and Ward
Psychological David B. Gill NH Recreation and
Park Association Yvonne Goldsberry,
PhD Community Health, Cheshire Medical
Center Travis Harker, MD Capital Regional Family
Health Care Martha Judson, RN Nutrition
Connections, UNH Cooperative Ext. Audrey Knight,
RN State of New Hampshire Department of
Health and Human Services Robert
Lister Portsmouth School System Susan Lynch,
MD Cholesterol Treatment Center, Concord
Hospital Sharon Malenfant , MS, APR The Memorial
Hospital Evelyn Mariani, RD St Joseph
Hospital Melissa McAllister, RD Anthem Blue
Cross Blue Shield
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Panel Members(continued)

• Louise McCormick, PhD Department of Health and
  Human Performance,
• Plymouth State University
• Mary McGowan, MD Cholesterol Treatment Center,
  
• Concord Hospital
• Lila Monahan, MD, FAAP Partners in Pediatrics
• Southern NH Medical Center, Nashua
• Katherine Rannie, MSc, RN Education Consultant,
  Office of School Health
• State of New Hampshire
• Heidi St. Hillaire, RN Elliot Hospital
• Evie Stacy, MS, ARNP Center for Life Management
• Lisa Sutherland Hood Center for Children and
  Families,
• Dartmouth Medical School
• William Tombari, MD Derry Pediatrics, PA
• Ellen Turcotte Whitefield School
• Jennifer Warren, MD Physicians Healthy Weight
  Center
• Rick Wilson, MD Lakes Region Health Care

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National Recommendations

• Institute of Medicine
• US Surgeon General
• American Academy of Pediatrics

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National Recommendations
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Whose responsibility is it?
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Its not easy
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The problem is not the lack of explanations for
the increase in childhood obesity, but the
abundance of them

• Paxton, C., Donahue, E., Orleans, C.T., Grisso,
  J. A. Introducing the Issue. The Future
  of Children. v16(1) 3-17, 2006.

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Causes of Overweight Obesity
Kaiser REGIONAL HEALTH EDUCATION
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Whose responsibility is it?

• Many people believe that dealing with
  overweight and obesity is a personal problemit
  is also a community responsibility
• -- Surgeon General Satcher

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Who should be involved in prevention of childhood
obesity?

• Its a community effort!
• Clinicians
• Hospitals
• Schools
• Day care centers
• After school programs
• Community centers
• Parks and recreation
• Family resource centers
• Worksites

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Its not easy
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Make it easier to do better

• Make it practical
• Simple, easy message
• Tools and resources
• Evidence based and promising practices

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The Result

• Recommendations
• Families
• Clinicians
• Schools
• After school programs
• Community centers, parks and recreation, etc.
• 5-2-1-0 message endorsement
• 5-2-1-0 tools for clinicians and communities
• List of resources to support recommendations

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Small Steps

• Pick the low hanging fruit
• Build from there!

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RecommendationsFamilies

• Positive role models
• Breastfeeding first 4-6 months
• Variety fruits and vegetables, whole grains
• Portion control
• Internal hunger cues
• Not using food as a reward
• Physical activity as part of daily routine
• Outdoor play
• Limit screen time to
• Talk to pediatrician

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Clinical Recommendations

• BMI
• Universal BMI screening and
  documentation on
  growth charts
• Assessment
• Physical activity, basic diet,
  and
  screen time
• Mental health issues
• Educate parents patients
• Growth curve and BMI
• Dietary advice
• Fruit and vegetable consumption more matters!
• Whole grains
• Limit soda and sugar sweetened beverages
• Limit 100 fruit juice
• One hour or more of moderate to vigorous physical
  activity/day
• No more than 2 hours of screen time per day

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Clinical Recommendations(cont)

• Language
• Sensitive and non-judgmental.
• Focus on the health of the patient, not their
  weight.
• Continuing education
• Motivational interviewing
• Improve comfort and effectiveness
• Office systems
• Increase awareness of/develop partnerships with
  community resources

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Recommendations for SchoolsNutrition

• You can
• In all areas where food is sold
• Decrease foods high in fat, sodium, and added
  sugars.
• Provide water or skim/non-fat or 1 milk, not
  soda or other sugar sweetened beverages.
• Limit 100 fruit juice.
• Ensure a variety of fruits and vegetables.
• Post nutrition education materials.
• Sell healthy, nutritious foods in fundraisers or
  use non-food items.
• Refrain from using food as a reward/discipline.
• Educate parents about healthy snacks and lunches.

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Schools-Nutrition (cont)

• Work with school officials to
• Modify school cafeteria menus, a-la-carte
  offerings, vending, and other foods
• Foods available contribute to major food groups
  of food guide pyramid
• Eliminate deep fryers and avoid purchasing
  pre-fried foods (baked instead)
• Use whole grain foods
• Offer only healthy, appealing foods in vending
  machines
• Involve students
• Provide adequate time (20 minutes) and space for
  lunch
• Make healthy choices highly visible and price
  competitively

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Schools-Nutrition (cont)

• Pre-service and in-service training to food
  service staff
• Recipe modification
• Healthy foods on a tight budget
• Planning healthy menus based on foods available.
• Promoting healthy eating
• Partner to offer nutrition education (hospitals,
  UNH Cooperative Extension, etc.)

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Recommendations for SchoolsPhysical Activity

• You can
• Activity events (walks, hikes, etc.)
• Promote life-long, non-competitive activities
• Refrain from withholding recess as a punishment
• Promote active recess time
• Recess walking program (map a route!)
• Walk/bike to school program
• Endorse/promote
• Physical education 50 class time being active

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Schools- Physical Activity (cont)

• Work with school officials to
• Aim to assist every child in accumulating
• 60 minutes of physical activity every day
• Expand physical activity opportunities for
  students clubs, lessons, intramural and
  non-competitive sports and activities.
• Partner with others in your community!
• Daily physical education for all students
• Physical education teachers are certified and
  highly qualified
• Use curriculum-based programs as appropriate
• Allow facilities to be available to community
  during non-school hours

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Recommendations for Schools General

• You can
• Assessment
• Communicate results- use as educational
  opportunity
• Develop and action plan based on results
• Monitor and evaluate progress
• Promote healthy lifestyles among staff
• Health focused field trips
• Local businesses for sponsorship
• Work with school officials to
• Provide training to school nurses
• BMI measurement and classification
• Motivational interviewing

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Schools- General (cont)

• Measure BMI once a year in ALL students
• Ensure privacy
• Communicate results to parents, not students,
  along with other health tests
• Use appropriate language
• Focus on health of student, not weight
• Educate about health risks
• Inform and educate parents/community beforehand
• Ask local health care organizations to assist

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Schools- General (cont)

• Provide community education
• Aggregate BMI results
• Value of physical activity and healthy eating
• Open houses, health fairs, family nights and in
  newsletters
• Increase awareness regarding the efforts of
  schools and their wellness committees.
• Provide media literacy training
• Health education- provide behavioral skills
  training relating to physical activity and
  nutrition.

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RecommendationsAfter School, Community Centers,
Parks and Recreation Depts.Nutrition

• You can
• Educate children and provide
  healthy snacks
• Ask parents to supply healthy snacks
  and lunches-give examples!
• Use water and skim/low-fat milk
  instead of soda or other sugar
  sweetened beverages
• Refrain from using food as a reward/discipline
• Sell healthy foods in fundraisers, or use
  non-food items
• Hold healthy family dinners/events
• Events? Invite vendors who offer healthy foods

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After school, Community Centers, Parks and
Recreation Depts.Nutrition (cont)

• Next steps
• Offer only healthy, appealing foods in vending
  machines.
• Integrate information about healthy eating in
  programs such as art, music, math, etc.
• Consider adopting a healthy snack policy.

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RecommendationsAfter school, Community Centers,
Parks and Recreation Depts.Physical Activity

• You can
• Summer programs ensure kids receive 60 minutes
  of physical activity/day.
• Incorporate physical activity into programs
  Lifelong, non-competitive activities that are all
  inclusive.
• Avoid taking physical activity away as a
  punishment.
• Endorse and promote
• Substitute non-educational screen time with
  activity programs.
• Promote programs to schools, pediatricians,
  community organizations.

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RecommendationsAfter school, Community Centers,
Parks and Recreation Depts.Physical Activity
(cont)

• Next steps
• Make activities available to all children at
  reasonable costs
• Increase access
• Work with local schools

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RecommendationsAfter school, Community Centers,
Parks and Recreation Depts.General

• Educate parents
• Support local initiatives in publications
• Integrate a wellness plan into goals
• Evaluate efforts
• Partner with community organizations
• Provide education and training to staff

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The Result

• Practical recommendations
• Families
• Clinicians
• Schools
• After school programs
• Community centers, parks and recreation, etc.
• 5-2-1-0 message endorsement
• 5-2-1-0 tools for clinicians and communities
• List of resources to support recommendations

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5-2-1-0

• Massachusetts BCBS promotes 5-2-1
• Maine Center for Public Health
• KeepMEhealthy 5-2-1-0 Power Up!
• Pediatric and family practices
• Schools

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5-2-1-0Supporting Literature

• Patrick, K. et al. Diet, physical activity, and
  sedentary behaviors as risk factors for
  overweight in adolescence. Arch Pediatr Adolesc
  Med V 158, p. 385-390, 2004.
• Gable, S. et. al. Television and frequency of
  family meals are predictive of overweight onset
  and persistence in a national sample of
  school-aged children. Journal of the American
  Dietetic Association. V 107,1, p. 53-61, 2007.
• Dennison et. al. Television viewing and
  television in bedroom associated with overweight
  risk among low-income preschool children.
  Pediatrics V 109, p. 1028-1035, 2002.
• Crespo, et al. Television watching, energy
  intake, and obesity in US children. Results from
  the third national health and nutrition
  examination survey, 1988-1994. Arch Pediatr
  Adolesc Med V 155, p. 360-363. 2001.
• Giammattei, J. et. al. Television watching and
  soft drink consumption Associations with
  obesity in 11 to 13 year old schoolchildren. Arch
  Pediatr Adolesc Med V157, p. 882-886. 2003.
• Faith, MS et al. Fruit juice intake predicts
  increased adiposity gain in children from low
  income families Weight status-by-environment
  interaction. Pediatrics V118(5) p. 2066-2075,
  2006.
• Wang, YC, et. al. Estimating the energy gap
  among US children A counterfactual approach.
  Pediatrics V118(6) p. e1721-e1733, 2006.

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The Result

• Practical recommendations
• Families
• Clinicians
• Schools
• After school programs
• Community centers, parks and recreation, etc.
• 5-2-1-0 message endorsement
• 5-2-1-0 tools for clinicians and communities
• List of resources to support recommendations

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Clinician Tools
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5-2-1-0 Survey
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Posters
Draft designed by Square Spot Design
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Family tools
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The Result

• Practical recommendations
• Families
• Clinicians
• Schools
• After school programs
• Community centers, parks and recreation, etc.
• 5-2-1-0 message endorsement
• 5-2-1-0 tools for clinicians and communities
• List of resources to support recommendations

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Resources

• Evidence based and promising programs
• Local and national resources promoted
• Presentation slides
• recommendations
• childhood obesity
• 5-2-1-0 message 5-2-1-0 materials
• Clinician tools, guides
• Posters
• Education handouts

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Community Prevention and Treatment
InitiativeChildhood Obesity Project

• Aims to bring communities together to collaborate
  on developing coordinated strategies for the
  prevention and treatment of childhood obesity.
• Clinical practice interventions
• Community strategies

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The CPTI Model
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Community Prevention and Treatment
InitiativeChildhood Obesity Project

• 3 pilot communities
• Nashua
• North Conway
• Derry/Londonderry
• Guiding documents
• NH Childhood Obesity Prevention recommendations
• Evidence-based and promising practices
• Local assessments

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Summary

• Focus on health, not weight.
• It takes a community effort.
• Partner with others in your community.
• Small changes can help get you started but build
  from there.

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Questions?

• For more information contact
• Beth at Bwheeler_at_healthyNH.com