Center for Child Health, Behavior and Development
Prevention and Treatment of
Childhood Obesity
Jason A. Mendoza, MD, MPH
Associate Professor of Pediatrics
University of Washington
Benton Franklin County
Medical Society CME
February 2015
Center for Child Health,
Behavior and Development
Presentation goals
• Scope of the Obesity Epidemic
• Prevention
• Safe Routes to School (SRTS)
• Treatment
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Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Center for Child Health,
Behavior and Development
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Center for Child Health,
Behavior and Development
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Center for Child Health,
Behavior and Development
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Center for Child Health,
Behavior and Development
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Center for Child Health,
Behavior and Development
Obesity Trends* Among U.S. Adults
BRFSS, 2009
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Center for Child Health,
Behavior and Development
Obesity Trends* Among U.S. Adults
BRFSS, 2013
Center for Child Health,
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Obesity among US children and adolescents aged 10 to 17 in 2003
Singh, G. K. et al. Arch Pediatr Adolesc Med 2010;0:2010.84-10.
Center for Child Health,
Behavior and Development
Obesity among US children and adolescents aged 10 to 17 in 2007
Singh, G. K. et al. Arch Pediatr Adolesc Med 2010;0:2010.84-10.
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Global Obesity Problem
Center for Child Health,
Behavior and Development
Responsibility
• Personal:
• Individuals make choices & “get what they deserve”
• Ignores children’s developmental status and impact of
family, school, and community environments
• Collective:
• Individuals make choices but within the influence of
the environment
• Create a healthier “default” setting through policy
and environmental changes
*Brownell et al, Health Affairs 2010
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Environment and policy
• Environment:
• Built environment
• Availability/access (parks, grocery stores)
• Foods offered in a school or business
• Policy:
• Costs of foods; incentives for behaviors
• Regulation of environments, i.e. sidewalks for new
housing developments
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Behavior and Development
Ecological approach
Sallis JF et al. Annual Review of Public Health. 2006;27(1):297-322
Center for Child Health,
Behavior and Development
Obesity Care Model
Barlow S E Pediatrics 2007;120:S164-S192
Center for Child Health,
Behavior and Development
©2007 by American Academy of Pediatrics
Background
Childhood obesity highly prevalent in US
• 16.9% of 2-19 year olds were obese in 2011-12
(Ogden et al, 2014)
• 18.4% of 4 year old were obese in 2005 (Anderson
et al, 2009)
• 31.2% American Indian/Native Alaskan
• 22.0% Hispanic
• 20.8% Black
• 15.9% White
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Background
Pediatric obesity tracks strongly into adulthood
(Whitaker et al, NEJM 1997)
• Obese 15-17 year old: OR=17.5 (7.7-39.5)
• Adolescent obesity tracks most strongly into adulthood
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Obesity complications
From: CDC Vital Signs 2010
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Behavior and Development
Obesity is costly; Prevention saves $
Health care spending for obesity est. $210 billion (2008) or
21% of US GDP (Cawley and Meyerhoefer, J. Health Econ. 31:1
(Jan 2012): 219–30)
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Obesity treatment
Childhood obesity highly prevalent
• Can clinicians provide effective services to 1/3 of ALL
children and adolescents in the US, i.e. overweight and
obese?
Behavioral treatment interventions
• Modest success but required >25-75 hours therapy
(USPSTF 2010)
• Most clinicians cannot provide intensive multidisciplinary therapy
Focus on Preventing Obesity
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Behavior and Development
Childhood Obesity Prevention
7-5-2-1-0: a useful menemonic
•
•
•
•
•
7 days a week eat a healthy breakfast
5 serving of fruits and veggies/day
2 hours or less of screen time
1 hour or more of physical activity
0 sugared drinks – water/lowfat milk instead
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The state of physical activity in the United States?
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Physical activity in the US
Troiano et al. MSSE 2008;40(1):181-188
Center for Child Health,
Behavior and Development
Decline in physical activity, 9-15 year olds in US
Average Weekday and Weekend Minutes of MVPA by Gender
Nader, P. R. et al. JAMA 2008;300:295-305.
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Physical activity built into our days
Center for Child Health,
Behavior and Development
Background
Physical activity is important for prevention of:
•
•
•
•
Obesity
Cardiovascular disease
Type 2 Diabetes/insulin resistance
Multiple types of Cancer
Physical activity is positively associated with cognitive and
academic outcomes among children
• Higher physical activity or fitness = higher scores
• Suggests benefits of physical education and recess
Center for Child Health,
Behavior and Development
Active commuting to
school:
The journey to school
matters
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Background
In 1969, 48% of US children walked or biked to school vs.
only 13% in 2009 (McDonald et al 2011)
Active commuting to school (ACS): appears promising to
increase physical activity
• ACS = walking and cycling to school
• ↑ACS is an objective of US Healthy People 2020
Barriers to ACS
•
•
•
•
Safety concerns
Distance to school
Weather
School policy
Center for Child Health,
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ACS, Physical Activity, & BMI
NHANES study
•
•
•
n=789, 12-19 year olds
Accelerometer-determined MVPA
Height , weight , waist, and skinfolds measured per protocol
•
Results:
• ACS positively related to daily MVPA (β=0.12, P=0.024)
• 30 min ACS  additional 4.5 min MVPA
• ACS inversely related to BMI z-score (β=-0.07, P=0.046)
• ACS inversely related to skinfolds (β=-0.06, P=0.029)
Mendoza JA, et al. J Phys Act & Health. 2011;8(4):488-495
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What is this?
*From Zhu X. and Lee C. Active Living Research Annual Conference 2007
http://activelivingresearch.com/files/Plenary_Zhu_0.pdf
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Walkable?
*From Zhu X. and Lee C. Active Living Research Annual Conference 2007
http://activelivingresearch.com/files/Plenary_Zhu_0.pdf
Center for Child Health,
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Walkability
*From Zhu X. and Lee C. Active Living Research Annual Conference 2007
http://activelivingresearch.com/files/Plenary_Zhu_0.pdf
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Walkable and Bikeable
www.pedbikeimages.org | Dan Burden (top images) | Carl Sundstrom (bottom images)
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Safe Routes to School (SRTS)
In the US, federally funded SRTS program began in 2005
after successful pilot programs
• Part of the federal Safe, Accountable, Flexible, Efficient Transportation
Equity Act: A Legacy for Users (SAFETEA-LU)
• Major goal: Promote walking and bicycling to school safely by primary
and middle school students
• Consist of four core elements
• Education (for drivers)
• Enforcement (law)
• Engineering (sidewalk, road, built environment)
• Encouragement (for students/families, e.g. walking school buses)
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Safe Routes to School: infrastructure and
walking/cycling
More parents report children walking or biking to school after
Safe Routes to Schools project completion
% change in walking or biking to school
50%
45%
40%
35%
28.6%
30%
25%
19%
20%
20.6%
15.6%
13.7%
15%
10%
11.6%
12%
10.9%
6.7%
3.1%
5%
0%
Juan
Cabrillo
Murrieta Sheldon
Valley
West
Glenoaks Jasper
Randall
Mt.
Vernon
Cesar
Chavez
Newman
Boarnet MG, Anderson CL, Day K, McMillan T, Alfonzo M. Evaluation of the California Safe Routes to School Legislation: Urban form changes
and children’s active transportation to school. American Journal of Preventive Medicine 2005; 28(2S2):134-140.
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Pedestrian crashes, New York City, 2001–2010
DiMaggio C , and Li G. Pediatrics 2013;131:290-296
Center for Child Health,
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School-aged pedestrian crashes during school-travel hours, New York City
No
SRTS
DiMaggio C , and Li G Pediatrics 2013;131:290-296
SRTS
Center for Child Health,
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Walking school bus
A group of children led to school by parents/adults who
walk together along a set route (active commuting)
Addresses safety concerns: supervised period of physical
activity and pedestrian safety teaching
Pedestrian safety is modeled and taught
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Walk to school studies
Seattle: Quasi-experimental trial of the Walking
School Bus (WSB)
• Setting: inner-city public elementary schools in
Seattle, WA
• One intervention school and two comparison schools
• Intervention school with WSB had 18% more ACS vs.
comparison schools at 1-year (Mendoza, Levinger, and
Johnston, BMC Public Health, 2009)
Center for Child Health,
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Walk to school studies
Pilot randomized controlled trial of the WSB
Setting: Houston Independent School District,
elementary schools serving low-income families
Design: Cluster RCT of 4 intervention + 4 controls
schools
•
•
•
Convenience sample
Matched schools on race/ethnicity, SES, randomized schools
Fourth grade students
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Houston: WSB trial
•20 students, 5 WSB stops
•Total distance 1.1 miles
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Results: Active Commuting
% of week using ACS: Intervention vs. Control
Intervention
Group
29%
Control
Group
8%
*controlling for age, gender, baseline ACS, distance from home
Mendoza JA, Watson K, Baranowski T, Nicklas TA, Uscanga DK, Hanfling MJ. The Walking School Bus and
Children's Physical Activity: A Pilot Cluster Randomized Controlled Trial. Pediatrics. September 1, 2011
2011;128(3):e537-e544
Center for Child Health,
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Results: MVPA
Daily MVPA (min): Intervention vs. Control
Intervention
Group
2 min
Control
Group
5 min
*controlling for age, gender, baseline MVPA, distance from home
Mendoza JA, Watson K, Baranowski T, Nicklas TA, Uscanga DK, Hanfling MJ. The Walking School Bus and
Children's Physical Activity: A Pilot Cluster Randomized Controlled Trial. Pediatrics. September 1, 2011
2011;128(3):e537-e544
Center for Child Health,
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Safe Routes to School
• Information on the WSB and other Safe Routes to
School programs:
• http://guide.saferoutesinfo.org/
• http://guide.saferoutesinfo.org/walking_school_
bus/index.cfm
• http://www.saferoutespartnership.org/
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Where do we go from here?
Center for Child Health,
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Call to Action
Health care providers, researchers, and institutions as
community leaders – advocates for children and families
• School board or community organizations
• Businesses & chamber of commerce
• Community presentations
• Input to policy-makers and elected officials
• Help create the healthier “default” setting in your own
communities!
Center for Child Health,
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Think outside the box
Disease prevention in our communities for children and
families
• Community-based programs (SRTS) target multiple aspects of health to
reduce disease burden and healthcare costs
• Likely will have increased relevance once Medicaid Accountable Care
Organizations become more prevalent
Transformation: hospitals’ community outreach  central
core of hospitals’ mission for improving patients’ health
(expertise, staff, resources)
• Affects patients and the hospitals’ bottom line ($$)
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Pediatric Obesity
Screening & Management
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Pediatric BMI Categories
1. Measure height and weight
2. Calculate BMI
3. Plot on CDC growth chart to obtain BMI percentile
• Some EMRs provide automatically
• http://nccd.cdc.gov/dnpabmi/Calculator.aspx
Barlow S E Pediatrics 2007;120:S164-S192
Center for Child Health,
Behavior and Development
Universal assessment of obesity risk and steps to prevention and treatment.
Barlow S E Pediatrics 2007;120:S164-S192
Center for Child Health,
Behavior and Development
©2007 by American Academy of Pediatrics
Prevention Plus
Basic lifestyle eating and activity habits to improve BMI
• More frequent monitoring and visits vs. prevention
• 7-5-2-1-0 mnemonic
• Involve entire family in lifestyle changes
• Child should self-regulate meals, avoid overly restrictive
feeding behaviors
• Tailor to cultural values
Center for Child Health,
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Prevention Plus
Implementation pointers:
• Work w/ families to choose a behavior(s)
• Use a stepped approach, e.g. 15 min activity to work up
to >60 minutes
• Tailor frequency of visits with family
• Primary care office and team
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Prevention Plus
Implementation pointers:
• If no improvement in 3-6 months, offer/refer Structured
Weight Management
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•
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Dietitian to develop a daily eating plan
Motivational interviewing techniques; counselor for parenting skills
Physical therapist or exercise therapist
Monthly visits
Group sessions possible
If no improvement in 3-6 months, offer a referral to a Comprehensive
Multidisciplinary Intervention (e.g. pediatric weight management center)
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Lipid management of overweight/obese children
Fasting
Non-Fasting
If abnormal:
obtain
fasting lipids
Figure 2.
Published in Childhood Obesity. August 2014, 10(4): 304-317.
DOI: 10.1089/chi.2013.0120
Center for Child Health,
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Risk Factors for CVD
High Risk
• Parent/grandparent/uncle/aunt h/o premature CVD (Dx <55 y.o. ♂;
65 y.o. ♀), coronary atherosclerosis, PVD, cerebrovascular disease,
or early deaths before 50 y.o. of unknown cause in relatives
• BMI ≥ 97th %ile
• Type 1 or 2 DM
• HTN (bp ≥ 99th %ile + 5 mm Hg, requiring therapy)
• Smoker
• Chronic renal disease
• H/o solid organ kidney or heart transplant
• H/o Kawasaki disease w/ current coronary aneurysms
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LDL management for high risk lipid profiles
Published in Childhood Obesity. August 2014, 10(4): 304-317.
DOI: 10.1089/chi.2013.0120
Center for Child Health,
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Center for Child Health,
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Triglyceride management
Published in Childhood Obesity. August 2014, 10(4): 304-317.
DOI: 10.1089/chi.2013.0120
Center for Child Health,
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Evaluation of abnormal liver enzymes
Published in Childhood Obesity. August 2014, 10(4): 304-317.
DOI: 10.1089/chi.2013.0120
Center for Child Health,
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Hypertension evaluation & management
Published in Childhood Obesity. August 2014, 10(4): 304-317.
DOI: 10.1089/chi.2013.0120
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Questions?
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