Distributed Responsibility and Child Health

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Distributed Responsibility and Child Health
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Diabetes (ADA) November 2007

• 1.5 Billion people with obesity worldwide
• Obesity has a 100 billion/year cost in US
• Physical activity is 1500 kcals/day less than 60
  years ago
• 60 of all Type 2 diabetes attributable to weight
  gain
• 353 million Type 2 diabetics in 2030 (175 now)
• New field of Inactivity Physiology commences
• Lap Time proportional to MI occurrences, CVD and
  CV fatality
• Poverty leads to high sugar and fat grocery
  selection as a means to obtain necessary calories
  in a day BUT leads to easier means to overshoot
  calorically

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Distributed Responsibility and Child Health
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Physical Activity A new concept?

• Lack of activity destroys the good condition of
  every human being, while movement and methodical
  physical exercise save it and preserve it
• Plato (427-347 BCE)

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Seeking a Healthy Lifestyle
to find a shortcut to
putting activity into a stressful life
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• Teens' Herbal Product Use Associated With Illicit
  Substance Use 26 Mar 2006 University of Rochester
  Medical Center study published in March in the
  Journal of Adolescent Health. The study found
  that teens who have ever used herbal products
  are 4.4 times more likely to have ever used
  inhalants4.4 times more likely to have ever used
  LSD, PCP, ecstasy, mushrooms, and other illegal
  drugs5.9 times more likely to have ever used
  cocaine6.8 times more likely to have ever used
  methamphetamines8.1 times more likely to have
  ever used IV drugs8.8 times more likely to have
  ever used heroin14.5 times more likely to have
  ever used steroids than teens who have never
  used herbal products.

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Lifestyle

• THE GOOD LIFE
• in search of the good life (consumerism)
• in search of an easier life (conveniences)
• in search of a life that is good (wealth)
• in search of a healthy lifestyle

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Lifestyle Management

• The practice of handling, supervision, or control
  of a way of life or style of living that reflects
  the attitudes and values of a person or group

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WANT TO
SHOULD DO
MUST DO
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Habit is habit, and not to be flung out the
window by any man, but coaxed downstairs a step
at a time. Mark Twain
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Self Esteem

• Self-esteem "the disposition to experience
  oneself as competent to cope with the challenges
  of life and as deserving of happiness"
• Enhanced self-esteem results when success is
  improved relative to expectations.
• Lower expectations - create realistic goals.
  Improve your chances of success!

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?
Where have our attitudes and values taken us..
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Body Mass Index

• Used to crudely assess population health
• BMI
• Mass / (Height 2)
• 80 kg / 1.83 m 2
• 23.8
• Adults
• Above 25 is overweight
• Above 30 is obese
• Not so useful for a person

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http//www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htmM
etric
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BMI and Health risk
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Risk Classification using Body Composition and
Physical Activity
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Insidious

• Working or spreading harmfully in a subtle or
  stealthy manner

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Obesity Trends Among Canadian and U.S. Adults,
1985
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Obesity Trends Among Canadian and U.S. Adults,
1990
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Obesity Trends Among Canadian and U.S. Adults,
1994
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Obesity Trends Among Canadian and U.S. Adults,
1996
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Obesity Trends Among Canadian and U.S. Adults,
1998
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Obesity Trends Among Canadian and U.S. Adults,
2000
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Prevalence of Obesity Diabetes Among US Adults,
1991 2001
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Obesity is a Major Risk Factorfor Type 2 Diabetes
Age-adjusted relative risk of type 2 diabetes
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100
BMI
1 JM Chan et al. Diabetes Care 2 G Colditz et
al. Ann Intern Med 17961-969, 1994
122481-486, 1995
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Tremblay et al. Int. J. Obese., 2002
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Tremblay et al. Int. J. Obese., 2002
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Above 20 is associated with existence of 1
marker for CVD
46.7 of 5-19 year olds is 113,000 Manitoban
children!
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Obesity Trends Among Canadian and U.S. Adults,
2010
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Whos Responsible?
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There is a little McDonalds in all of us.
Super sized Quarter Pounder with cheese 590 or
Crispy Chicken 500 Fries 610 Coke 410 TOTAL
1520-1610 kcals 300 min walk, 161 min moderate
exercise, 80 min of 5 min/miles
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Snack Time

• Miss Vickies Chips
• 1 chip
• 10 kcal
• 20 push ups
• 80 jumping jacks
• 1 minute run
• 10 minutes of sitting

• Crispy Minis
• 1 mini
• 7.5 kcal
• 15 push ups
• 56 jumping jacks
• 45 second run
• 7.5 minutes of sitting

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A mismatch of output and input (FoodgtActivity)
results in storage of extra calories as fat. A
mismatch as little as 180 kcals (a granola
bar) will result in 18.7 lbs of adipose
accumulation.
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Silent Sneaky Calories

• Large coffee, double double
• 230 kcals
• 3 times a day 690 kcals
• Large coffee double milk, double sugar
• 150 kcals, 3X 450 kcals
• Large coffee single cream, single sugar
• 120 kcals, 3X 360 kcals
• 1 week 2/3 lb fat per week, 2 hours 20 min at 7
  mph on treadmill! 8 hours of brisk walking!!!!
• 1 week 5 coffees a day 1.1 lb per week!

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Generation
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The Couch as a villain

• The couch existed in the 50s
• The couch is still here today.
• However, behavior modification through Flipping
  the couch interesting.
• What would most do??

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The problem
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The mouse as a disease carrier
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Average Daily Time Spent Using Media, by Age
Group, 1999
Total Use 619 in 1999 621 in 2004 About 7
hours a day of leisure time!
N 3,155 children, ages 2-18 (nationally
representative) margin of error 3-5 Source
Kaiser Family Foundation. Kids and Media at the
New Millennium, 1999, 2005
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Generation

• 1999
• TV 304
• Videos/DVD 59
• Print 43
• Audio 148
• Computer 27
• Video game 26
• SUM 729

• 2004
• 305
• 111
• 43
• 144
• 102
• 49
• 833

Total Use 619 in 1999 621 in
2004 Multi-tasking!!!!!! Hard environment to
pull a child out of.
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Source Andersen et al. JAMA 1998279938-942.
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Current Physical Inactivity Levels in Canadian
Youth, 12-19 y
Physical Inactivity lt3.0 kcal.kg-1.day-1
Source 1998 NPHS, www.cflri.ca, 2002.
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Current Physical Inactivity Levels in Canadian
Adults, 20 y
National 55
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59
59
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Physical Inactivity lt1.5 kcal.kg-1.day-1
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Source 1998 NPHS, www.cflri.ca, 2002.
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Physical Work Capacity Adverse Myocardial
Events
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CAUSES OF FATAL CANCER
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Physical Activity Cancer
Friedenreich Orenstein (2002)
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Physical Activity Adherence by Children in
Manitoba
52.2 accumulated lt30.0 min, 31.1 accumulated
30.0 to 59.9 min, 12.7 accumulated 60.0 to 89.9
min 4.0 accumulated 90.0 min.
(Wittmeier, Mollard and Kriellaars, 2007)
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Pre-pubescent girls have substantially more
adipose than boys.
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Our Prairie Children
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Daily Step Counts in Our Children
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Weekend
Weekday
4000 steps shy of target
7000 steps shy of target
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Step Count Guidelines for Healthy Adults/Children

• 5000 steps/day sedentary lifestyle
• 5000 - 7,499 s/d typical or low active
• 7500 - 9,999 s/d somewhat active
• 10,000 s/d active
• 12,5000 s/d highly active
• 12,000 16,000 active children

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Pedometer Interventions Aid - but cant be used
all the time.

• 16 week rivalry based pedometer intervention
  (Grade 6, n77, three countries) 4198 steps/day
  increase! 10 children lost more than 10 lbs.

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Remove female activity inequity in early years.
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Manitoban Children and Step Count Standards

• 16,000 steps/day for males and 13,000 for females
  - Duncan et al 2007
• 20 of females and only 10 of males
• 15,000 steps/day for males and 12,000 steps per
  day for females - Tudor-Locke et al. 2004
• 22.7 female, 14.3 of males
• In Winter 7

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Pedometer Interventions Aid - but cant be used
all the time.

• 16 week rivalry based pedometer intervention
  (Grade 6, n77, three countries) 4198 steps/day
  increase! 10 children lost more than 10 lbs.

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The ODDS Are?
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The Five Rs (32)
Reading
wRiting
aRithmetic
Relationships
The 5th R
Regular Physical Activity Real Nutrition
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Recommendations

• Enable Recess Put Play Back in Recess
• Trained recess supervisors (MPESA/TA)
• Add incentives to some recesses (pedometer,
  walking, etc)
• Add semi-structure to some recesses (games)
• Accessible and varied equipment (sex specific)
• Create activity plans for indoor recesses
• Playground upgrades (color coded) not just play
  structure
• Seasonal play structures that work in winter
• 1-2 m Berms (not hills)
• Outdoor footwear (added to indoor gym footwear)
• BACK-PAC enabled
• Advice from PE on recess through PAC (Parent
  Advisory Council) on PAC (Physical Activity
  Council)
• Manage liability, cooperative and competition
  imperatives relative to inactivity
• Recess Commission
• Create resource (division independent resource
  team PE EP REC)

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Parental Influence Role Model
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Parental Energy Index (Lytle et al, 1999)

• How often do you talk about this issue with your
  child?
• School work
• Chores
• Getting along with the family
• Safety-helmets, seatbelts
• Avoiding cigarettes
• Avoiding alcohol, marijuana and other drugs
• Avoiding violence
• Friends they choose
• Eating habits
• Getting more physically active

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LAP Disease

• LAP disease is a disease where the percentage of
  time spent with a LAP far exceeds the time spent
  without a LAP.

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Not only is having a lap associated with physical
inactivity But it is a great place for
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LAPS
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Sugar Consumption
50 teaspoons per day!!!
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CT of the femur the shape changes with
activity!
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1
3
4
6
2
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Sedentary
Active Control
5
1
3
4
6
2
7

• The shape of the bone is very important in
  strength
• Activity and inactivity dramatically change
  shape!!

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Immobile
Active
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Increased risk of obesity per can or serving of
sugar-sweetened beverage
4.8
3.2
Risk of Obesity
1.6
Servings of Sweetened drinks
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Dieting
Food
Physical Activity
Decrease fat mass Decrease muscle mass Decrease
skeletal mass Decrease CV function
BUT Short-Term Caloric Restriction Induces
Accumulation of Myocardial Triglycerides and
Decreases Left Ventricular Diastolic Function in
Healthy Subjects
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Exercise
Food
Physical Activity
Decrease fat mass Increase muscle mass Increase
skeletal mass Increase CV function
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Exercise and Over-eating ControlEat Like a Pig,
Run Like a Dog
Physical Activity
Fuel
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in the shadow of the bulge
moral responsibility of the community
d. j. kriellaars
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Distributed Responsibility and Child Health
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Recommendations

• Provide teeth to PE/HE report cards
• Report on physical activity status
• Report on health status
• Report on nutrition status (portion control
  understanding)
• Modify curriculum to have an objective to
  quantify change in PA (promotion to provision)
• Engage PE specialists to have BACK-PAC role
• Provide mechanism to have generic category
  specific lifestyle modification programs
  developed for deployment to students in need of
  PA enhancement
• Tie health status to PE - to match current level
  of association of sport with PE.
• Facilitate and resource fitness lifestyle
  courses (Glenlawn Lisa Hill)

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Recommendations

• Recognize and recommend the use of competency
  trained and competency evaluated lifestyle
  interventional specialists
• Certified Exercise Physiologists (Canadian
  Society of Exercise Physiologists, Health Canada)
  only 40 in province
• Physiotherapists (gt600 in province)
• Other
• Some Physical education specialists (gt500 in
  province)
• Some athletic therapy and kinesiology graduates
• Some other certified exercise professionals
  (ACSM, NSCA)

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Recommendations

• Support the training of CSEP Certified CEP at
  University of Manitoba
• Graduate a min of 20 per year
• Employ CEP in RHA
• Add CEP to 3rd party insurers list of health
  care providers
• Publish advisory information to public regarding
  competencies of personal trainers
• Engage Physiotherapy profession to enhance their
  role in lifestyle intervention

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Recommendation

• Recognize severe limitations (impossibility) of
  traditional health care system for lifestyle
  intervention for those overweight and for primary
  prevention (do not place the role in the health
  care hands) not likely primary health care
  model due to lack of competency!
• Obesity Prevention and Treatment Clinic
• Free standing
• 4 CEP, 2 PT, 1 Nutritionist, 1 MD, 1 Nurse
  (referral options)
• Non-Health Care Model
• Programmatic based (lifestyle intervention model
  used by CEP of CSEP)
• Home visits
• Streamlined access
• provide services tailored based upon likelihood
  of change
• Feasible option to non-credible clinics
• U Weight Loss Clinic, Herbal Magic, etc.

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Recommendations

• Fund objective measurement surveillance in
  Manitoba
• Accelerometry Anthropometrics
• About 600 children X 4x/year
• About 1000 adults (2x/year)
• Fund Interventional Projects
• 1-2 year projects
• Examine interventional practices to provide best
  practice kits
• Recess Interventions
• Fitness Classes for Credit
• BACK Pac
• PA Periods
• Nutritional Interventions
• Accelerometry, anthropoemtrics, self-esteem,
  academics, etc

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Recommendations

• Recognize unique nature of snow climate in
  interpretation of non-snow cover research
• Create Think and Practice Tank for agencies and
  groups to access lifestyle service advice
• Experts in the area full time
• Also responsible for surveillance
• Create Junk Food Levy to fund PA initiatives
  akin to enviro levy

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Recommendations

• Dont overemphasize a holy grail effect from
  daily PE it is a piece of the puzzle.
• Dont fight the drink machine waste of effort -
  redirection
• Dont vilify objects or corporations attitudes
  and values not computers/MSN and McDs.
• Social marketing campaigns without adequate
  programming resources have very poor (adverse)
  historical outcome (Participation).
• Restoration of walking to school may not be
  part of the new reality?
• Emphasize total disease risk reduction and
  benefits of activity over obesity reduction.
  Prevent dysfunctional attitudes.
• Steps per day may not be enough will need to
  progress in intensity.

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Given a choice between changing and proving that
it is not necessary, most people get busy with
the proof.
John Galbraith
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What is a Pedometer?

• An electronic device that counts the number of
  steps you take
• A valid measure of daily physical activity by
  simply counting steps
• Provides feedback to motivate

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Are all pedometers the same?
We would all love to have a cheap (free or under
10) pedometer that works Sorry accurate
pedometers cost more (22 or more). Inaccurate
ones lead to frustration (they undercount steps)
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What does it look like? Parts?
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Inside step count and reset.
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Inside Inside gizmos for detecting steps and a
battery.
Weight moves Up and down with each step
Weight hits this Switch to detect Step. Not
enough jiggle and no step detected
spring
battery
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Where do I wear it? Best Place? Left side hip
region.
Try 100 steps it should read 98 to 102 if not
try a different place
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Where do I get one?

• www.stepscount.com
• 1.866.342.2328 ask for Halley Sears

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So now all I need is start walking
Keep track of normal daily steps
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Step Count Guidelines for Healthy Adults/Children

• 5000 steps/day sedentary lifestyle
• 5000 - 7,499 s/d typical or low active
• 7500 - 9,999 s/d somewhat active
• 10,000 s/d active
• 12,5000 s/d highly active
• 12,000 16,000 active children

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Want to, Should do, Must DoBreaking the
Distributed Responsibility Problem! Attitudes
and ValuesRealistic goals Performance not
weight Activity food not food alone
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Distributed Responsibility and Child Health
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Lunch Time. Dinner Time. Prime Time.
LG Refrigerator With Built-In LCD TV
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Myths and Facts

• Benefits come from activity
• Want to, should do, must do
• Consistency is king
• Form follows function
• Performance goals
• Wealth without health
• 10,000 steps a day
• Realistic fat loss
• 400 kcals/day
• What is your health worth?
• 50 plasma - for activity
• Seek qualified help (exercise professionals (PT
  PFLC)

• Fat Burning Zone
• Dont focus on weight
• Weight cycling
• Dysfunctional diet rotations
• Spot reduction
• Fat burning foods!
• Low this and that (low carb, low sat fat, no
  trans fat, low protein) its calories folks
• A healthy diet is not a healthy life
• All natural is better or safe
• There are no shortcuts!!!!

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Pedometry
www.stepscount.com
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October 2006
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Kcals/kg Per day
Walk Time
Walk Distance
Mod Ex Time
Vigor Ex Time
Steps
Calories
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Upon reflection, how do you see yourself?/ Body
image - internal representation of ones own
outer appearance which reflects physical and
perceptual dimensions.
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Caloric Balance
150 kcals/day 15.5 lbs fat/year
Energy Expenditure
Energy Intake
1. Exercise 2. Activity of Daily Living 3.
Resting Metabolic Rate
1. Over-consumption 2. Recommended Caloric Intake
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How do I get there!

• Increase physical activity output
• Walk 3500 steps more a day
• 30 minutes of walking a day
• 2x/week to daily over a few weeks
• Training Partner buddy, a pedometer, a log, a
  calendar, etc.
• Dont overeat
• Reduce intake of food to match output (this could
  mean 600 kcals a day 6 slices of bread.
• Know the calories in food
• Limit convenience foods (easy access)
• Limit portions
• Drop 150-300 kcals per day of food
• Patience

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Caloric BalanceLifestyle Intervention
3500 kcals/week 1 lb fat 2-3 lbs weight
Energy Expenditure
Energy Intake
1. Exercise 2. Activity of Daily Living 3.
Resting Metabolic Rate
1. Curb Over-consumption 2. Caloric Intake
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Discipline it is not about blame.

• One step at a time!
• Yes I do have time!
• I will find a way! it may not be the first way
  in the next 6 weeks I will find a way to get
  activity back in my life
• There will be blips! plan for them
• I will not be a failure! Just need to find the
  right path.
• No cookie cutter or simple solution solutions
  need to be tailored to you!

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One need not walk this path alone.
Secure the future of one and others, break
through the distributed responsibility barrier.
There is not a single group or agency that a
person can seek or identify to help. Worse yet,
they often point at the wrong group.
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Recess
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PE Class
SOURCE U.S. Department of Education, National
Center for Education Statistics, Fast Response
Survey System (FRSS), "Foods and Physical
Activity in Public Elementary Schools 2005,"
FRSS 87, 2005.
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Weighing Students and Notifying Parents

• In 2005, the Institute of Medicine recommended
  that schools conduct annual physical assessments
  of their students' weight, height, and body mass
  index (BMI), and that schools send this
  information to parents. According to our survey,
  two-thirds of public elementary schools never
  calculated students' body mass index, 28 percent
  never measured students' height, and 29 percent
  never measured students' weight. Moreover, only
  28 percent of all public elementary schools
  notified parents about the students' weight or
  their height, and only 17 percent informed
  parents' about the students' body mass index.

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Understanding the Causes

• Obesity prevention involves a focus on energy
  balance--calories consumed versus calories
  expended--so taking action against childhood
  obesity must address the factors that influence
  both eating and physical activity. Although it
  appears straightforward, these factors result
  from complex interactions across a number of
  social, environmental, and policy contexts.
  American children live in a society that has
  changed dramatically in the three decades over
  which the obesity epidemic has developed.

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Developing an Action Plan for Prevention

• This report presents an action plan that consists
  of explicit goals and recommendations for
  preventing obesity and promoting a healthy weight
  in children and youth in different segments of
  society. The obesity epidemic is a serious public
  health problem that calls for immediate action to
  reduce its prevalence as well as its health and
  social consequences. Therefore, the committee
  felt strongly that actions should be based on the
  best available evidence--as opposed to waiting
  for the best possible evidence.
• Presently, there is limited experimental evidence
  regarding the best ways to prevent childhood
  obesity and the extent to which various potential
  factors contribute to weight gain. For these
  reasons, the committee chose a process that
  integrated all forms of available evidence to
  formulate the report recommendations. As actions
  are taken, evidence should be collected to assess
  whether they have made a difference in reaching
  childhood obesity prevention goals.

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Definition of osteoporosis
Normal
Osteoporotic
A progressive systemic skeletal disease
characterized by low bone mass and micro
architectural deterioration of bone tissue, with
consequent increase in bone fragility and
susceptibility of fracture.1
1.WHO, 1994. Osteoporosis Clinical Guidelines for
Prevention and Treatment. RCP July 2000
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Bone quality

• Bone architecture is another key part bone
  density and architecture are required for maximum
  bone strength

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Quantitative Computed Tomography CT
Dual Energy X-ray Absorptiometry DEXA
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Inactivity and altered loading changes the inside
structure of bones!
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Loss of Cortical Shell the veneer covering the
bones is lost with inactivity!
Femoral CT Slice immediately proximal to knee
joint line
CT Raw
200 mg/cc threshold
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Health problems associated with Physical
Inactivity and Over-consumption in developed
countries
Greatly increased
Moderately increased
Increased
(relative risk gtgt3)
(relative risk 2-3)
(relative risk 1-2)

• Diabetes
• Gall bladder disease
• Hypertension
• Dyslipidemia
• Insulin resistance
• Breathlessness
• Sleep apnea

• Coronary heart disease
• Osteoarthritis (knees)
• Hyperuricemia and gout
• Psychosocial problems (depression, esteem)
• Osteoporosis

• Cancer (breast cancer in postmenopausal women,
  endometrial cancer, colon cancer)
• Reproductive hormone abnormalities
• Polycystic ovary syndrome
• Impaired fertility
• Low back pain
• Increased anaesthetic risk
• Fetal defects arising from maternal obesity

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Health benefits associated with Physical Activity
Greatly increased
Moderately increased
Increased
(relative benefit gtgt3)
(relative benefit 2-3)
(relative benefit 1-2)

• Bone quality (density and architecture)
• Muscle mass, fibre type, oxidative capacity
• Cardiovascular function
• Physical capacity (leisure and work)

• lean body mass
• fat mass reduction
• pain tolerance
• coordination

• Self-esteem

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Getting all our ducks in a row