Are Current Health Care Practices Propagating Obesity in our
Youth?
The Role of the Physician to Prescribe Solutions
Thomas M. Best, MD, PhD, FACSM
The Ohio State University
Improving People’s Lives
through innovations in personalized health care
Sports Medicine
What Motivates Change?
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There is a crisis
A critical mass of scientific evidence exists
Shift in social attitude occurs
Public cynicism grows
Political pressures begin to build
What Motivates Change?
• There are 2 kinds of disease; one is pathological,
the other is political
Physical Exercise offers protection
against a cluster of diseases
Type 2 diabetes
Cardiovascular
Diseases
Breast cancer
Depression
Colon cancer
Pedersen BK. J.Physiology 2009
Dementia
Exercise Deficit Disorder (EDD) in
Youth
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Walker GA, Edwards NM, Stracciolini A, Faigenbaum AD, Myer GD. The Use of Exercise-specific V
Codes and Reimbursement at a Large Pediatric Medical Center. AMSSM 2013.
Comprehensive Management Strategies for
Management of EDD in Youth
Myer, GD, Faigenbaum, AD, Stracciolini, A, Hewett, TE, Micheli, LJ and Best, TM (2013). "Comprehensive Management
Strategies for Physical Inactivity in Youth." Current Sports Medicine Reports July/August.
Lecture Overview
• Discuss the paradox that exists in
youth fitness and sports today.
• Review the wide ranging benefits
of PA in kids and implications of an
inactive youth population.
• Talk about current messaging on
youth health behaviors
• Discuss the role of the physician
and healthcare systems in
assessing and prescribing exercise.
Youth Fitness and Sports Paradox
• Survey of HS seniors:
– Less than 25% of boys and 15%
of girls exercise vigorously .
– Childhood obesity is an
emerging epidemic.
• However;
– Half the exercising group is
actively involved on an athletic
team, many participating all
year.
– Increased risk for orthopedic
injury, especially related to
overuse.
Youth Fitness and Sports Paradox
• The Changing Landscape
of Playgrounds!
– Most exercise obtained by
children in America is no
longer obtained in physical
education class or free
play; it comes through
organized youth sports.
– Children are less fit and
obesity is growing, yet so is
athletic injury!
Physically Inactive kids at greater risk
for injury!
• Study of 995 children aged 9-12
years.
– Low levels of habitual PA have
significantly increased injury risk.
• The children at highest injury risk
are the target audience of the
contemporary PA promotion
efforts.
• Therefore, PA promotion should
focus on injury prevention as well.
Bloemers BJSM 2011
Benefits of Physical Activity in Kids
Why Kids Should Exercise
• Compared to kids who don’t
exercise, kids who do:
– Can run longer and faster
– Have stronger bones
– Have stronger muscles
– Are less likely to be fat
– Have less stress and depression
– Are less likely to develop chronic
diseases
– Are more likely to be healthy
adults
Exercise Helps Prevent:
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Diabetes
Cancer (breast and colon)
High blood pressure
Depression
Osteoporosis
Alzheimer’s disease
Heart attacks
Dying early
Physical Activity Improves Mental
Health
• Regular PA may increase self
esteem
• Regular PA may decrease
anxiety/depression*
• Some evidence shows teen girls
have lower rates of sexual activity
and pregnancy when PA increased
• Some evidence regular PA
associated with decreased
smoking, alcohol and drug abuse
K.J. Calfas, W.C. Taylor. Ped Exerc Sci 1994. 6:406-423
Sabo et al. J Adolesc Health 1999;25:207-16
Fitness And Stanford Achievement Test
9th Ed
SAT-9 and Fitnessgram Results
• Fitnessgram test:
– 1.
– 2.
– 3.
– 4.
– 5.
– 6.
Aerobic Capacity
Body Composition (% of body fat)
Abdominal Strength and Endurance
Trunk Strength and Flexibility
Upper Body Strength and Endurance
Overall Flexibility
Grade 5
SAT 9 and Physical Fitness
353,000 Students
80
70
Reading
Mathematics
71
SAT 9 Percentile
60
58
50
50
45
40
30
36
29
40
32
36
55
46
40
20
10
0
1
2
3
4
5
Number of Fitness Standards Achieved
Source: California Dept. of Education Study, December 10, 2002
6
Grade 7
SAT 9 and Physical Fitness
322,000 Students
70
SAT 9 Percentile
60
Reading
66
Mathematics
60
54
50
50
40
41
30
20
26 28
31 32
34
44
36
10
0
1
2
3
4
5
Number of Fitness Standards Achieved
Source: California Dept. of Education Study, December 10, 2002
6
Grade 9
SAT 9 and Physical Fitness
279,000 Students
70
SAT 9 Percentile
60
Reading
67
Mathematics
58
50
51
40
38
35
30
20
45
43
28
24
21
37
31
10
0
1
2
3
4
5
Number of Fitness Standards Achieved
Source: California Dept. of Education Study, December 10, 2002
6
Socioeconomic Status** & Number of Fitness Standards
2004 CST* Scores in English- Grade 5
371,198 Students (203,726 NSLP and 167,472 Non-NSLP)
380
CST E-LA Math Score
370
Non-NSLP
NSLP
360
350
340
330
320
310
300
0
1
2
3
4
Number of Fitness Standards Achieved
*California Standards Test
**National School Lunch Program
Results using math scores were consistent with those using English-Language Arts scores.
Results for seventh- and ninth-grade students were consistent with those for fifth graders.
Source: California Physical Fitness Test, 2004 Results, Calif. Dept. of Ed., April 2005
5
6
Improvements in Fitnessgram Results
PE 4 Life Program at 6 months
Woodland Elementary School, Kansas City PSD
Fall 2005 – Spring 2006, Grades 4 and 5
13.5 %
Modified Sit & Reach
Fall 2005
21.6 %
Spring 2006
 60%
16.5 %
Push-Up
 88%
31.1 %
12.4 %
Paced Curl-Up
 127%
28.1 %
19.4 %
Pacer Test
(Cardiovascular Fitness)
Flexibility Test
 207%
59.6 %
4.5 %
 182%
12.7 %
3%
Strength Test
 433%
16 %
0%
10%
20%
30%
40%
50%
60%
70%
Percent Reduction in Disciplinary Issues
PE 4 Life Program at 6 months
Woodland Elementary School, Kansas City PSD #33
Fall 2005 – Spring 2006, Grades 4 and 5
Discipline
Incidents
Involving
Violence
2004 - 2005
2005 - 2006
228
 59%
94
Resulting
Out-of-School
Suspension
Days
1177
 67%
392
0
200
400
600
800
1000
1200
1400
Fitness and Neurocognitive Function
in Preadolescent Children
• 24 children, mean age, 9.6 years
• Fitness assessed by FITNESSGRAM
• Neurocognitive function assessed by
responses to a stimulus discrimination task
• Fitness was positively associated with
attention, working memory, response speed,
and cognitive processing speed
Hillman CH et al. Med Sci Sports Exerc 2005; 37:1967
How Much Physical Activity Do Kids Need?
• Children and adolescents should do 60 minutes
(1 hour) or more of physical activity daily.
– Aerobic Activities: most should be either
moderate or vigorous intensity PA. Include
vigorous-intensity PA at least 3 days per week.
– Muscle-strengthening Activities: at least 3 days of
the week, as part of the 60 or more minutes.
– Bone-strengthening Activities: on at least 3 days of
the week, as part of the 60 or more minutes.
• Activities should be age-appropriate, enjoyable, and
offer variety.
Kids exercise less as they get older
Boys weekday
14.7 yrs
Girls weekend
12.6 yrs
JAMA. 2008;300(3):295-305. doi:10.1001/jama.300.3.295
% of High School Students Meeting
Guidelines
100
Percent
80
60
40
20
23.7
17.1
18.5
15.5
14.9
Black
Hispanic
10.5
0
Total
Female
Male
White
* Were physically active doing any kind of physical activity that increased their heart rate and
made them breathe hard some of the time for a total of at least 60 minutes/day during the 7 days
before the survey.
Source: National Youth Risk Behavior Survey, 2007.
When are elementary school students
active?
8000
7000
Steps per day
6000
5000
4000
Boys
Girls
3000
2000
1000
0
P.E.
School Day
Outside
School
Morgan CF, et al (2003) Journal of Physical Education Recreation and Dance,
74(7), 33-38.
NHANES
Prevalence of Overweight Youth Ages 2-19
Chronic Disease in Children
• Pediatrics; Nov 08’
Number of children taking
meds for chronic diseases
jumped dramatically in
past 3 years.
– Diabetes 103% increase
(kids as young as 5)
– Asthma 47% increase
– ADHD 41% increase
– Cholesterol 15%
increase
Where will we find our future?
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Firemen
Police officers
Prison guards
Soldiers
Lifeguards
Construction
workers
“The Freshman 15?”
• Studies suggest actual
weight gain during 1st year
of college is:
– ~6 lbs in men
– ~4.5 lbs in women.
• What are the causes?
– Not enough exercise.
– Poor diet – fast food,
dormitory food, skipped
meals.
– Poor sleep habits
– Stress.
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2000
1990
2010
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Hysteria
• The world has now been
sufficiently alerted to the
global problem of obesity.
• Patients have been
labeled and stigmatized.
• Assigned lots of blame.
• Spent lots of money.
• …and gotten nowhere.
Are patients and their physicians giving up?
• Data from National Ambulatory Medical Care
Survey for 1995-96’ and 2007-08’ showed:
– During this period, adults who were overweight or
obese increased from 52.1% in 95’ to 63.3% in 08”.
– Patients seen in 2007-08; had 46% lower odds of
receiving weight counseling than 95-96’.
– Patients with hypertension 46% less likely and diabetics
59% less likely to receive counseling.
• The campaign on obesity is not working!
• What’s the definition of insanity?
Kraschnewski, et al, Medical Care, 2013
We need a new (and fresh) approach!
• We need to give patients
permission to be fat; And still
be healthy!
• Shift focus off of BMI and
onto physical activity.
• Health At Every Size (HAES)
– Focus on broader health.
– 95% regain lost wt. in 3-5 yrs.
– Change in BMI is not a success
measure for an exercise
program.
Death Rates by Fitness & BMI
Categories
70
Low fit
Mod fit
High fit
Deaths/10,000 MY
60
50
40
30
20
10
0
<27
Normal
27-30
Overweight
Barlow et al. Int J Obes 1995; 19:Suppl 4, S41-4
>30
Obese
after adjustment
for health status,
smoking, glucose,
cholesterol, & BP
What can we do?
• Large scale exercise prescription
initiative in adults and kids:
– Every patient; Every visit;
Every treatment plan.
• Physical activity should be
recorded as a vital sign and kids
encouraged to do 60 min of
exercise per day.
• Message should be the same from
every medical provider.
• We must begin to merge fitness
with healthcare.
Smith, Johnny
12 yrs M
What Can Busy Physicians Do to
Encourage Physical Activity?
 0 Minutes:
Running late? Too many other concerns on the patient’s
list? Relax. Perhaps you can discuss physical activity at
next visit. Hopefully office staff will have assessed
exercise and provided resources.
1 Minute for Advice:
Quickly congratulate kids (and their parents) who are
getting 420 minutes or more per week of moderatevigorous physical activity.
Advise patients who are getting fewer than 420 minutes
of the importance of physical activity, especially linking
benefits to the child’s complaints, problems and health
risks.
What Can Busy Physicians Do to
Encourage Physical Activity?
2 Minutes for a Prescription:
 Review key messages about the importance of physical
activity.
 Offer a generic Exercise Prescription.
 Suggest useful ideas (e.g. walk to school, bike transportation,
active games, after-school activity, family fitness activities).
5 Minutes for Brief Counseling:
 Assess readiness for change regarding exercise habits.
 Ask what the child might want to do to be more active and
barriers to prevent this from happening -- brainstorm on
how to get around them.
 Explain to parents in detail how exercise affects health and
development and their child can go about incorporating it
into their life.
EVS in Kids; Kaiser Permanente
• Days per week in 153,746 kids
age 12-17 (year ending
1/31/13):
– 15.2% report 0 days per week.
– 15.7% report 1-4 days per week.
– 69.1% report 5 or more days/wk.
• Percent reporting >150 min mod
exercise per week:
– 77.5% in 12-17 yrs.
– 34.5% in 18-64 yrs.
– 29.8% in 65+ yrs.
“At Kaiser Permanente, we want you to
Live Well, Be Well and THRIVE!”
Kaiser Permanente – “Kid Wisdom”
Summary
• Youth sports/activity paradox – kids are doing
too much or too little.
• The wide ranging benefits of PA in kids and
adults are well established.
• We need to encourage kids to be Healthy at
Every Size by engaging in regular PA.
• Physician have an important role to play in
promoting PA for health
– An Exercise Vital Sign is an easy way to bring a
discussion on PA into the exam room.
– Even brief advice can have a significant affect.
A Call-to-Action
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Mississippi State
U of Arizona
Georgia Tech
Lewis & Clark College
U of South Florida
Joliet College
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Roanoke College
UCCS
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