Childhood Obesity: Design and Results of the TTUHSC Healthy Kids Clinic Comparison of clinical vs. school-based interven

1. Childhood Obesity: Design and Results of the TTUHSC Healthy Kids ClinicComparison of clinical vs. school-based intervention Cecilia Moore, MS, RD, LD TTUHSC Department of Pediatrics Lubbock, Texas

2. Objectives • Identify at least 2 major lifestyle contributors to overweight/obesity in the pediatric population 2-19 years of age. • Evaluate the pros vs. cons of the clinical setting using data from the TTUHSC Healthy Kids program. • Compare the pros vs. cons of the school-based setting as an intervention

3. Prevalence of Obesity* Among U.S. Children and Adolescents(Aged 2 –19 Years)National Health and Nutrition Examination Surveys Data from NHANES I (1971–1974) to NHANES 2003–2006 show increases in overweight among all age groups: Among preschool-aged children, aged 2–5 years, the prevalence of obesity increased from 5.0% to 12.4%.8, 46 Among school-aged children, aged 6–11 years, the prevalence of obesity increased from 4.0% to 17.0%.8, 46 Among school-aged adolescents, aged 12–19 years, the prevalence of obesity increased from 6.1% to 17.6%.8, 46

4. The 2007 national Youth Risk Behavior Survey indicates that among U.S. high school students: • Overweight 13% were obese. • Unhealthy Dietary Behaviors 79% ate fruits and vegetables less than five times per day during the 7 days before the survey. 34% drank a can, bottle, or glass of soda or pop (not including diet soda or diet pop) at least one time per day during the 7 days before the survey. • Physical Inactivity 65% did not meet recommended levels of physical activity. 46% did not attend physical education classes. 70% did not attend physical education classes daily. 35% watched television 3 or more hours per day on an average school day. 25% played video or computer games or used a computer for 3 or more hours per day on an average school day.

5. Reasons for the Prevalence of Childhood Obesity Genetic predisposition: • Twin studies estimate that 65% to 75% of the tendency to obesity is inherited. Heritability of obesity greater than schizophrenia, alcoholism and atherosclerosis. Inheritance is mostly polygenic and varies. • Weight Set Point Hypothesis Every individual has a genetically inherited “set point ” that governs “ideal” body mass. Environmental factors influence this set point and determine actual body mass.

6. Environmental influences: • Availability of high caloric density, palatable food. Since the early 1900’s consumption of fats and sugars increased by 67 and 64%, vegetables decreased by 26%. • Advertising to children. On average a child sees 10,000 ads a year and 90-95% are for sugared cereals, fast food, soda, candy • Portion Distortion: Serving Sizes are Growing Several studies published in 2003 document increases in portion sizes for many popular foods. This amounts to an additional 50-150 calories per meal. • Movement Towards a More Sedentary Lifestyle

7. Serving Sizes Then and Now • Food or beverage • 1950sExpanded 2003 • French fries   2.4 ounces   up to 7.1 ounces • Fountain soda   7.0 ounces   12 to 64 ounces • Hamburger patty   1.6 ounces   up to 8.0 ounces • Hamburger sandwich   3.9 ounces   4.4 to 12.6 ounces • Muffin   3.0 ounces   6.5 ounces • Pasta serving   1.5 cups   3.0 cups • Chocolate bar   1 ounce   2.6 to 8 ounces

8. Rate of weight gain when calories consumed equals calories required for normal growth and development. 50 calories per day over daily requirement 100 calories per day over daily requirement Rate of weight gain due to “extra” calories

9. IS OBESITY A DISEASE IN CHILDHOOD? • Obesity is associated with insulin resistance and metabolic syndrome • 65% of obese 5-10 year old children have at least 1 cardiovascular disease risk factor • hypertension, hyperlipidemia, abnormal glucose tolerance • 25% of obese 5-10 year old children have 2 or more risk factors Dietz WH.JPediatr1999;134:535-536

10. Obesity: other associations and complications • Obstructive sleep apnea • Fatty liver disease with steatosis (NAFLD, NASH) • Orthopedic problems (SCFE, osteoarthritis) • Hypertension, pulmonary hypertension • GERD • Diabetes • Pubertal disorders • Chronic kidney disease • Polycystic ovary syndrome

11. Changing the Incidence of Childhood Obesity - Society? Very hard to effect “global change” when a majority of the population either is not at risk or doesn’t perceive it as “their problem”. How can we outlaw video games when we can’t even regulate more “obvious” health risks like cigarettes, and alcohol?

12. Pediatric Weight Loss Programs in Community • Mostly hospital, or clinic-based. Some are franchised, for fee. • Education on healthy eating, parenting, behavioral modification • Variable duration, curricula • High attrition rates (50-60%) • Lack of published data on effectiveness of intervention • Most do not involve significant exercise component (lack of resources, liability issues) • Limited evidence of sustainability of weight loss • Expensive

13. Taking a look at a clinical intervention: Healthy Kids Clinic • Healthy Kids (overweight/obesity) clinic • Texas Tech University Health Sciences Center • Department of Pediatrics • Lubbock, TX • Established in 2006 • Purpose: to provide a clinical approach to the childhood obesity epidemic in the area

14. Multidisciplinary Team • Pediatrician/Pediatric Endocrinologist • Registered Dietitian • Psychology graduate student • Exercise & Sports Sciences graduate student

15. Original Plan • Appointments upon referral • 1st visit: meet entire team for assessment • Bi-monthly follow-up visits with RD, and psychology • Exercise opportunities twice a week • Follow up visits with MD every 3 months • Provide an individualized plan to aid in weight control and implement healthy lifestyle changes for the entire family

16. Issues along the way • MOTIVATION! • Bi-monthly visits • Follow-up visits with MD • Scheduling • Graduate students – new students, new training, different experiences • Changes with the exercise portion of the intervention – TTU Recreation Center, Fitness and Wellness

17. Clinic Trends: 2008-2009 • Collected data for 2 years • Total referrals to Healthy Kids 2008: 130 • Total referrals for 2009: 138 • ~85% from Lubbock area • ~15% from surrounding area

18. Percentage of referrals from different age groups About 8 % of our referrals were siblings in 2008, and 5% in 2009.

19. Referrals: Gender

20. Ethnicity: Comparison of 2008-2009

21. Referrals: Ability to Schedule

22. Show Rate: Initial Visit

23. Follow-up rate

24. Weight Trends • Randomly looked at 70 patients • 100% of those seen at their initial visit had BMI’s > 95th percentile (highest: 53.8 kg/m2, 15 yo female, 51 kg/m2 17 yo male • Success is individualized based on: • Age: weight loss vs. weight maintenance • BMI trends • Compliancy with goals: were we able to make some progress with changing lifestyle habits? • Improvement in labs

25. Trends cont… • About 20% of this group had some sort of success at some point • However, about 21% of these patients, when last seen, had an increase in BMI • Weight loss/maintenance was seen more in those who visited once every 1-2 months • When more time lapses between visits = more weight gain!

26. Issues • Individualized vs. group? • MOTIVATION! • Assessment of readiness-to-change is not occurring at pediatrician’s office first • Patience – takes time to get to goal • Scheduling issues • Clinic days • Appointment times available • Issues with the routine of how appointments are scheduled • Location/setting

27. Positives • Multidisciplinary team • Individualized • Emphasizes family support • Ability to recommend other subspecialty referrals • An option that can work for some

28. The School Health Policies and Programs Study 2006 indicates that among U.S. high schools: • Health Education • • 69% required students to receive instruction on health topics as part of a specific course. • • 53% taught 14 nutrition and dietary behavior topics in a required health education course. • • 38% taught 13 physical activity topics in a required health education course. • Physical Education and Physical Activity • •95% required students to take physical education; among these schools 59% did not allow students to be exempted • • 2% required daily physical education or its equivalent for students in all grades in the school for the entire year. • •45% offered opportunities for students to participate in intramural activities or physical activity clubs. • School Environment • • 18%, students could purchase fruits or vegetables. • • 77%, students could purchase soda pop or fruit drinks that are not 100% juice. • • 50%, students could purchase chocolate candy. • • 52% did not allow students to purchase foods or beverages high in fat, sodium, or added sugars during school lunch periods. • Nutrition Services • • 77% offered a choice between 2 or more different fruits or types of 100% fruit juice each day for lunch. • • 49% did not sell any fried foods as part of school lunch. • • 81% offered lettuce, vegetable, or bean salads a la carte

29. Role of Schools in Preventing Obesity • Schools are a critical part of the social environment that shape children’s eating and physical activity patterns • Lead by example: healthy food served while at school, and limited access to “junk food” • Provide access to and maintain healthy amount of physical activity while at school • Widen the school-home collaboration to promote child’s physical health and fitness

30. Percentage of secondary schools in which students could not be exempted from taking required physical education for certain reasons* 14% - 50% 51% - 71% 72% - 79% 80% - 96% No Data *Enrollment in other courses, participation in school sports, participation in other school activities, participation in community sports activities, high physical fitness competency test score, participation in vocational training, and participation in community service activities. School Health Profiles, 2008

31. Percentage of secondary schools in which students could not purchase other kinds of candy from vending machines or at the school store, canteen, or snack bar 23% - 63% 64% - 71% 72% - 83% 84% - 95% No Data School Health Profiles, 2008

32. Percentage of secondary schools in which students could not purchase salty snacks that are not low in fat* from vending machines or at the school store, canteen, or snack bar 28% - 57% 58% - 64% 65% - 76% 77% - 91% No Data *Such as regular potato chips. School Health Profiles, 2008

33. Percentage of secondary schools in which students could not purchase soda pop or fruit drinks that are not 100% juice from vending machines or at the school store, canteen, or snack bar 26% - 51% 52% - 62% 63% - 73% 74% - 93% No Data School Health Profiles, 2008

34. School-Based Interventions • Boarding schools (Wellsprings Academy) and Summer camps (“fat camps”):very effective, but not feasible for mainstream • School-based nutritional education programs • Gaining popularity, however greatly variable duration and curriculums • Published studies use BMI as outcome measure • Most show none or modest improvements in weight, BMI • Some show improved dietary habits • Little data on sustainability • Believed to be more effective than the hospital-based programs due to peer participation

35. An After School, Family-Centered Lifestyle Program:Collaboration Between Health Care Providers, After-School program Staff and Volunteers7th Annual Forum for Improving Children’s Healthcare & National Congress on Childhood ObesityMegan Lipton, MA, et al., 2008 Methods The study took place over the 2006-2007 school year at 8 matched elementary schools in low-income school districts in Los Angeles, San Jose, and Vacaville CA. Population consisted of 325 child participants and 229 parents, of which full data was collected on 232 children. Of these 232 individuals, 109 were in the intervention group and 123 were in the control group. Families at the intervention schools attended 6 weekly 3-hour classes consisting of didactic and interactive nutrition education, exercise, parental support and behavior change motivation. Control schools families were tracked throughout the year for comparison. Adiposity measures, nutrition knowledge and eating and physical activity behavior were measured. Results Overall students in the intervention group showed a significant 6-week decrease in BMI z-score compared to the control group, and a downward trend for body fat percentage. Neither the effect of intervention on decrease in BMI z-score nor the downward trend for body fat percentage in the intervention was affected/altered by adjustment for age, gender, or school location.

36. Why schools? • Other than families, many aspects about the education setting have a large influence on children’s lives • Majority of time during the day is spent at school • 1-2 meals are provided • 1-2 snacks • Where they will get their first official lesson on health, nutrition, and physical activity

37. Issues • Funding • Adequate staff • Food production contracts • Medical issues of the individual might be missed • Others?

38. Obesity Treatment: Basic Modalities • Lifestyle intervention: utmost importance • Clinical vs. school setting interventions • Along with community assistance • Medical therapies: reserved for severe obesity, very limited pharmacological agents available for children. Effective but results not sustainable • Surgical treatment in cases with poor prognosis in older adolescents