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This document discusses the pediatric obesity initiative at Cleveland Clinic Children's Hospital. It begins by establishing obesity as the most prevalent chronic disease in childhood. It then discusses the scope and definition of obesity, prevalence trends, and consequences of obesity like hypertension, diabetes and social stigma. The document outlines Cleveland Clinic's key objectives to address obesity through prevention education, clinical treatment programs, and community outreach. It provides examples of school-based interventions and curriculums to teach nutrition literacy. Data from studies on a BMI screening program and a pediatric weight loss program are presented. Finally, it discusses using comprehensive policy and environmental strategies modeled after anti-tobacco efforts to most effectively address the obesity epidemic.
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Presentation 1 ellen_rome[1]
- 1. Addressing Obesity in andout of the Office: The Pediatric Obesity Initiative at the Cleveland Clinic Children’s Hospital Ellen Rome, MD, MPH Head, Section of Adolescent Medicine Physician Leader, Pediatric Obesity Initiative
- 2. Why We Care Obesityis currently the single most prevalent chronic disease in childhood.
- 4. The Scope ofthe Problem • Genes and jeans- what we inherit and what we buy/feed our kids • For now, we can’t modify the genes part • HOW WE EAT: Patterns of eating learned from parents first, then from families, peers, society • Prevention of obesity is HIGHLY DEPENDENT on family dynamics • Treatment of obesity is HARD!!!!!
- 6. Definition of Obesity •Occurs when: energy intake > energy expenditure • Body Mass Index = wt (kg)/(ht in meters)2 • BMI 20-23 ideal for teens/adults • 120% of more of ideal body weight or BMI > 95% defined as obese • BMI > 30 = obesity in teens and adults • BMI >95% = obesity in younger children
- 7. Prevalence of Overweight(>95%)
- 8. Prevalence of Overweight(>95%)
- 9. Prevalence of Overweight(>95%)
- 10. Prevalence of Overweight(>95%)
- 11. 1998 Obesity Trends* AmongU.S. Adults BRFSS, 1990, 1998, 2007 (*BMI ≥30, or about 30 lbs. overweight for 5’4” person) 2007 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: CDC Behavioral Risk Factor Surveillance System.
- 12. Risk of AdultObesity •14% chance if obese as infant •25% chance if obese at preschool age •41% chance in obese at age 7 •75% chance if obese at age 12 •90% chance if obese in adolescence
- 13. Why We Care: Consequencesof Obesity • Hypertension (2.9 x higher in obese) • Diabetes (2.9 x higher in obese) • CAD • Hypercholesterolemia (2.1x higher) • Other hyperlipidemias • Mechanical stress on joints, SCFE • Blount’s disease (tibia vara) • Pseudotumor cerebri • Hepatic steatosis, cholelithiasis • Social stigma- depression, low self esteem
- 14. IF YOU REDUCEBMI by 10% … •BP decreases by 10 mm/HG (average) •TGs decrease below 100 mg/dl or by 200 (if genetic defect present) •HDL-C raised by 3-5 mg/dl •LDL-C sometimes lowered (diet/wt loss combined can lower LDL by 25- 30% if elevated)
- 15. What is AdiposeRebound? • In 1st few yrs of life, have low adiposity --> then begins to increase • Usually occurs between 4-6 yrs • The younger/heavier the child is at adipose rebound, the more likely to become an overweight adult • “…the adipose cells accumulated during this period will forever call out to be fed (Arriza, Peds Annals 2004)
- 17. Cleveland Clinic PediatricObesity- Key Objectives • Obesity prevention is part of every routine child health supervision visit • Increase clinical skill in identifying and treating overweight and obese children, including comorbidities • To expand our services for pediatric and adolescent obesity in our region, particularly for our underserved youth- in the community • To enhance care for the pediatric bariatric surgery patient • To perform outcomes analyses to measure impact of our program
- 18. Food Advertising • Onaverage, children ages 8-12 years see 7,600 food commercials a year • Food ads work • Almost all advertised foods are healthy –97.5% food ads are shown Sat am – promote high fat, high sugar, high cholesterol • Studies show that commercials increase liking for advertised foods
- 19. Power of theMedia • Kids only need to see an ad once or twice to influence their preferences • “Pester power” – increases kids’ demands of their parents
- 20. Teaching Media Literacy •What’s wrong with this ad? • 1/3 less sugar means – Higher fat – Higher sodium – Higher calories – Only lower in carbs by 1 gram – “Sugar” is a dirty word for parents
- 21. When To Doan Intervention? • Won’t work until child is ready to change; may actually do harm if done before child ready! • With the very young child, just need parents’ willingness to modify diet/exercise to ensure success • Can use motivational interviewing • May need family therapy, esp if parent with eating disorder
- 22. An Example- Janice •Janice comes to your program/office/facility. At age 10 years old, she has a BMI already of 30. Since kindergarten, she has been teased about her weight by peers, siblings, and extended family. • Parents/You want to protect her from low self esteem- what can you do???
- 23. Teasing and Overweight ProjectEAT • Assume overwt child or teen has been a victim of weight related teasing • Nearly half of girls in PROJECT EAT were teased by their family • Numbers likely an underestimate of what is happening-
- 24. Dinner time talk… •What kinds of things do you like about family meals in your home? What would you like to change? - Stay on safe, non weight related topics - The Special Plate • What are some ideas for making change happen?
- 25. Cut Out theWeight Talk • Encourage families not to engage in wt talk, about the child or themselves • Talking about wt, encouraging kid to diet/lose wt, wt teasing • “Oh my gosh, I look fat!” “You have to go on a diet, get off that couch now!” • “Talk less. Do more”. To make your home environment more conducive to healthy eating, incr phys activity, high self esteem
- 26. With Children andTeens • Let kids know that dieting and esp unhealthy wt control behaviors may be counterproductive • Help kids feel better about their bodies regardless of their size. If has child who is not a good reader, don’t want to make them feel stupid to help them read more… Do not use body dissatisfaction as a motivator for change. • Encourage family to have regular, enjoyable family meals • Assume overwt child has experienced wt related teens and address with children and their families
- 27. Janice • When youask Janice, she says that the teasing does bother her. She has thought about dieting and has cut out candy for the most part. She has switched from pop to juice to be healthy. She would not mind working on it with you. • How do you proceed?
- 28. What Can YouDo? • Focus on strategies that increase physical activity, healthy eating and weight control behaviors, sources of social support, and issues of weight-related stigmatization + self-esteem • Build exercise into family life/activities • HELP FAMILIES MAKE A FEW SMALL, PERMANENT CHANGES AT A TIME
- 29. Cleveland Clinic’s Countdown toHealth: 5 to GO! • 5 a day fruits and veggies • 4 dairy/calcium servings a day for teens • Give and get 3 compliments a day • 2 hrs or less tv/media time • 1 hr exercise/activity a day • 0 sugar-sweetened beverages
- 30. Stoplight Diet • Redfoods- avoid! • Yellow foods- proceed with caution • Green foods- GO!
- 31. Typical Behavioral Intervention •Identify the problem: too many RED foods • Brainstorm: Who is buying RED foods? Who brings RED foods home? Are there RED foods that could be changed to yellow or green? • Generate solutions: Plan weekly meals; buy healthy foods; make lunch rather than school lunch
- 33. The Role ofPhysical Activity in Weight Control • Dose to prevent obesity is unknown • Dose to maintain weight after loss around 1 hr/day • Relatively modest impact on weight loss • Reduces obesity associated comorbidities • Built environment needs to be conducive…
- 34. School-Based Reforms -Age SpecificCurriculum Food is Knowledge: (ages 4-6 yrs) Ten interactive lessons teaching students about food groups using cute characters, songs and poems. Teaches math, science, social studies, culture and hospitality. Healthy Futures: (grades 4-6). Ten week interactive wellness program that teaches students positive health-related behaviors. HealthCorps: (grades 9-12). In/after school seminars on diet, nutrition, exercise, mental health. Legislative efforts- school-based reform on PE requirements, vending machine/food service, BMI screenings Parent/Teacher Campaign Bully-proofing Community Initiatives - Access to GO! foods & Affordable Shopping - Partner with local grocery stores with cooking demonstrations, promote family dinners, Farmer’s Market to improve access to fruits/veggies - Community Coalitions- Ohio Business Round Table partnership fostering legislation - BMI Study- 17 inner ring suburbs, K-5th - Active Living Communities - Walking school bus - Built Environment: Playgrounds, green spaces, bike paths, other efforts Clinical Care - Fit Youth Programs for 8-12 yo’s, 13-18yo’s with BMI > 30, Weekly for 10 weeks Parental involvement Psychology, MD, Dietitian, Exercise Physiologist - 5 to GO! messaging in the office via motivational interviewing, from preconception on - Protein Sparing Modified Fast (MD + dietitian monthly) - Bariatric Surgery Ages Birth to 22 Cleveland Clinic Employee Benefits - Trans fat free campus - Healthy vending machine/food service offerings - Free Curves, Weight Watchers, Fitness facilities - Wellness incentives: Go FIT!
- 35. School-Based Interventions: Curriculums Food isKnowledge: (4-6 years). Ten interactive lessons teaching about the food groups using illustrated characters, songs, and poems. Uses food to reinforce math, social studies, language arts, science, art, culture. Healthy Futures: (grades 4-6). Ten week interactive wellness program that teaches students positive health-related behaviors. Topics include physical activity, nutrition, bone health, substance abuse, safety, and mental health. HealthCorps: (grades 9-12). In/after school seminars on diet, nutrition, exercise, mental health. Includes walking program, speakers, field trips, interactive experiences.
- 36. “One is good,two’s okay, Save the rest for another day!”
- 37. “Mealtime” from Food isKnowledge Mealtime at our house is so much fun! We all sit together ‘til we are done. We don’t just eat and run- run away… We sit and talk about what we do all day. So please tell your family To share in their meal, With love for each member And tell ‘em how you feel. For mealtime is not just the food you eat… It’s the sharing in your heart And the caring when you meet.
- 39. BMI Study: Lakewood CommunityFindings • 4th graders screened and interviewed, nutrition and physical activity habits surveyed, BMI measured. • 98/400 students overweight, 55 “at risk” • Correlating with BMI: low fruit, high junk food consumption • “At risk” kids had lower SES, lower academic achievement, and higher BMI • Limitations: NOT IRB approved, and reports correlations, NOT causation • Expanding BMI study to all of Cleveland’s greater ring suburbs
- 40. Fit Youth atIndependence • N = 72 children completed 10 week program: • Cumulative weight loss of group = 297 lbs • Average weight loss during group= 4.4 lbs • Greatest loss = 25.3 lbs • Greatest gain = 4.62 lbs • Percent who lost wt = 73.1% • Percent who gained wt = 25.4% • Percent who maintained= 1.5%
- 42. Using the TobaccoAnalogy • 25% of health care costs due to obesity-related morbidities • Solving the problem requires both policy and environmental changes implemented at the state and community level • Sidewalks, bike paths, safety- Fairfax project • School: healthy food, vending machine options, physical education requirements, after school programming (Cleveland Clinic as example) • Medical home helps, affordable/accessible meals, in school food that is healthy and fresh
- 43. Community Solutions • Inthe Workplace- Cleveland Clinic examples- transfat free, healthy options everywhere, no smoking, walking areas, Curves, Weight Watchers… • Policy: promote tax incentives for supermarket development and urban gardening in low-income neighborhoods • Encourage fast food restaurants to promote healthier options • Promote breastfeeding and smoke free pregnancies! • Create a bully-proof, tease-free environment!!!
- 44. New York CityDaycare Laws • TV, video and other visual viewing rules – No TV for <2yo – Limited 60 min per day of educational programs or programs that actively engage child movement for kids >2yo • 60 min physical activity required • Eliminated sugar-sweetened beverages • Provide 1% or no fat milk
- 46. Simple Messaging forFamilies • Family dinner counts! • Stop the weighty talk- and no teasing! • Change the built environment to make family and child activity inevitable and easy • Teach media literacy- decrease the “pester power” • In growing children, weight maintenance alone may be a good goal
- 47. We Can HopefullyAvoid This…