MCHB EPI Atlanta Conference
 
December 5 - 7, 2006

How to Meet the Challenge of Childhood Obesity

STEVEN GORTMAKER:  Thank you.  I hope everybody can hear me back there.  I tend to speak softly.  Okay.  We all know the problem, where we’re headed in this country and throughout the world and what I’d like to talk to for a little bit is about some school-based strategies to prevent obesity.  I’ll talk about Planet Health, how we got to our focus on certain behavioral targets, how we’ve worked to think about implementation and then I’d like to talk a little bit about, well, just a broader strategy, of course, while school-based intervention is important, how it can only be part of a really more comprehensive strategy.

First of all, let’s talk about the causes of the epidemic and the science of energy balance.  These slides, by the way, I’ll talk to them rather rapidly but they’ll make them available I guess after the conference is over.  We all know about the energy imbalance that’s driving the overweight or obesity epidemic.  The daily imbalance on average is kind of small.  We’ve calculated--we have a paper coming out or it’s just out in pediatrics a couple of days ago that actually estimates the imbalance driving epidemic.  It’s larger than people have thought about.  It’s maybe about 150 calories a day in excess across the average population in extra sugar-sweetened beverage a day.

For kids who are obese, it’s much greater, maybe four or five times that but it’s still something that’s manageable to think about and of course social context is important.  Wherever you go we have foods that we don’t need.  In fact, just for breakfast this morning, well, actually this was, well, the snack here but Froot Loops, I could’ve had Froot Loops for breakfast to--like all sugar and trans fats and for a snack here I got the Twister, which is what, a hundred and sixty calories of sugar water?  I’m sorry, but it’s everywhere.  Okay.  Let’s talk about what’s going on in the real world, what’s driving the epidemic.  We talked about school-based interventions but the big interventions are taking place in the real world.  The food producers in the fast food industry, they’re not bad people, they’re just doing their job and their job is to get everybody to eat more every single minute of every single day and they’ve been successful at this.

Sugar-sweetened beverages are a great example.  An extra can of sugar-sweetened beverage can lead to an excess of about five pounds per year.  We are papering and you can see how we do the calculations for stuff like this.  And in the United States, you’ve seen declines in intake of things like milk; you’ve seen increases in sugar-sweetened beverage intake.  We actually calculate--it’s unpublished now but I think kids, on average, are in taking about 250 calories a day of sugar-sweetened beverages.  We found in a study published in the Lancet a few years ago that each additional serving of sugar-sweetened beverage leads to increases in BMI and obesity incidence among kids.

There’s a couple of intervention studies now showing that actually if you reduce intake of sugar-sweetened beverages, you can reduce risk of overweight or obesity.  There are nice, randomized control trials with adults showing this.  I mean it’s the sort of research though, if you talk to people on the street, you really don’t need a Harvard study to tell people that if you intake sugar water, you’re going to add excess calories.  It’s interesting though, I mean this is not just a problem for kids and it’s one of the things I’ve got into talking about a lot--sugar sweetened beverages are a problem for the adult population too.  A nice study showing that increases in intake of sugar-sweetened beverages among adult women are directly linked to incidence of diabetes, the independent risk factor.  It’s kind of striking because there aren’t too many independent dietary risk factors.

That’s a sugar-sweetened beverage world and, of course, linked to that is the growth of the fast food industry and increasing portion sizes which are occurring throughout our population.  I took this picture at a McDonald’s about five, six years ago and it’s still a dollar.  It’s unbelievable how many calories you can get for a dollar.  It’s not all that stuff for a dollar but one of those.  I love this quote from my colleagues at Children’s Hospital--large fast food meal, you have a double cheeseburger, French fries, soft drink, dessert, this is 2,200 calories, which would require a youth a full marathon to burn off.  Being an ex-distance runner, I can say that I don’t think anybody should actually run a marathon let alone kids.  It just destroys your cartilage, why do you want to do that?  So that’s what we’re up against.  This is a first picture from the surface of Mars.  Our world has changed and the social norms around eating have altered with--dramatically.

We did a study recently, showing how fast food restaurants are clustered around schools--big surprise.  I mean that’s where the future population is.  All these social norms have changed.  This is kind of like--I remember that phrase, “Can Johnny come out and play?”  This is “Can Johnny come out and eat?”  We did a study where we looked at kids on days that they visited the fast food restaurant, and days that they didn’t, in a national sample, and those days that they did was an extra 126 calories a day, just walking into that environment you’ll consume more.  Make sense, right?

So its one part of this equation, that’s one part of the energy balance equation that’s been driving what this epidemic is all about.  The other part of this equation is the world of video and television.  If they’re successful we all sit more in front of screens and then watch endless ads about foods we should consume, and again, they’re not bad people.  I mean they make this fun and interesting, but it has a remarkable impact.

Obesity is related to TV viewing because it both increases dietary intake and it leads to more inactivity.  And actually, the dietary intake pathway is the bigger one.  Both of these are important but the dietary intake is really important, and there’re tons of studies showing this relationship, these are just a couple of studies we did.  Actually the first one published 21 years ago.  Direct relationship with longitudinal data and you think about TV commercials.  I like this quote from an Institute of Medicine Study, “Children currently view as many as 40,000 commercials on television and cable per year.”  Lot of that is for the kind of foods that--oh, actually, this kind of stuff exactly.

We did another recent study, each additional hour of TV viewing leads to 167 calories per day, extra.  It’s mainly because of this impact on dietary intake.  Couple of nice randomized control trials by Len Abstein show the same kind of result, but actually bigger effects, and other people are finding similar results just like this.

Again, its not just the problem for kids.  You probably can’t read this but it says, “Every few years Gordon and the TV getting a couple of inches wider.”  This is the legacy of our current lives.  Actually like this one, this guy is sitting there; he’s eating this thing called, “humongo snacks”.  This is where we’re headed, and it seems like a joke but this is the story of our culture.  This is the story of our life.

So there are interventions where you can make a difference and intervene on this.  The nicest one, our cleanest one is Tom Robinson’s study, published in FEMA, andLen Abstein has nice intervention work with obese kids, and then, of course, we did our Planet Health study, and I’ll talk about that as a school base intervention.

So all of these research back here is what’s lead us to focus on what we did in Planet Health, and what we’re doing in our next edition of Planet Health, which is coming out next summer, which will have more of the focus--same focus as before but additional focus on sugar, sweet, and beverages, whole grains, and good and bad fats.

In creating Planet Health and working with schools, what we tried to do is create something that was inexpensive, uses existing teachers, we wanted it to be science-based, and of course liked by teachers and students, which actually is the most important thing for dissemination on the population.  And the key issue, of course, as all of you know if you worked with schools, as today, its all about high-stakes testing, not about health education, or physical activity, or nutrition, but high-stakes testing.  So you have to make it fit in with the primary educational aims of schools and that we did by focusing on after learning literacy across the curriculum.  And the curriculum frameworks--we fit in with the curriculum frameworks, and just about every state that has them.

We have four very simple behavioral targets.  In our next edition we’ve added the fifth.  We have a little more focus on whole grains and reducing those excess carbs like, sugar sweeten beverages.  But we think it’s really useful to have just a few behavioral targets, and of course, TV viewing is one of those key ones, and we had number of intervention components, we have classroom components.  The key thing is that the lessons fit into existing classes:  math, science, language arts, social studies, as well as PE, make it also fit into health education.  That’s very flexible.  You can do it, implement it, arrange in different ways and we found effectiveness.

We found reductions in obesity among girls, slightly underpowered study actually, but we found these reductions.  We found reductions in TV viewing for both boys and girls.  It’s not that hard to reduce TV viewing.  There’s a huge literature showing that most of the time, kids are spending watching their three hours at TV a day, they’re not having a great time.  So if you get them thinking about things that they could do and creating alternatives, with--they’ll move in another direction.

We found bigger impacts in some schools then others.  We didn’t put this in the original article but we could’ve dropped this one school that didn’t implement it well and we really would have got a big effect and effects for boys, too.  But of course we couldn’t do that.  I mean, the original study.  We found the biggest impact for African-American girls.

In a follow up study of Bryn Austin, did a nice study showing that we actually got reduction in disordered weight control behaviors in the intervention schools.  And we think that’s because in the intervention, we never talk about obesity or overweight, we just talk about the healthy behaviors.  We want to encourage people to focus on.  I think that’s really important.  There’s a lot of stigma associated with overweight and obesity.

In our recent study we found that along with the reduction in obesity we had actually a little delay in onset of menarche.  In independent economic analysis of Planet Health found an estimated program cost to $14 per student per year is pretty inexpensive.  Most of that is teacher-training cost, which we think we’ve reduced a bit with online training.  And an estimated $4,300 per quality adherent to quality adjusted life here, which is similar to what you’d see for a variety of commonly accepted preventive interventions like hypertensions screening and treatment.

We’ve been lucky in having a bunch of partners who’ve been implemented, who have been interested in spreading this curriculum.  Blue Cross--Blue Shield has started a 3 million-dollar program to spread it throughout Massachusetts which has been really exciting and currently about 6,000 copies of Planet Health distributed in all 48 states and in more than 20 countries.

So looking back to the story here, that’s one program that we’ve developed.  But again with the big interventions out there are not--are Planet Healthy program implemented in some places or others programs like it but rather these forces and what do you do?  And I think it’s a bit pessimistic to think about the future but I think with the one hopeful thought I have is really to think about the fact that if we could take these few simple behavioral targets.  I mean Bill talked about them before.  We tried to focus on them in Planet Health.  And if we think, “Okay, what can we do outside the school?”

What we do at our Prevention Research Center, we’re funded by the CDC is to really make sure that we think broadly, okay?  It’s not just about individual choice.  We think about broad social, ecological approaches to changing things.  And we work with our community partners to develop and evaluate interventions within multiple social and environmental settings.  So we work within schools, preschools, after schools, primary health care, work sites, neighborhoods, and homes.  And our sense is that you want to get the same messages reinforced within these multiple environments and channels and that’s how we’re going to make a difference.

So we have some preschool work going.  Look at that picture of that kid, it’s great.  We have our Eat Well and Keep Moving Curriculum, which we developed with the bunch of partners in the Baltimore Public Schools.  It’s fourth and fifth-grade version of Planet Health.  We have Planet Health, I’ve talked about that and hear my colleagues on that.  We’ve been doing a bunch of work in primary care settings now.  The Maine Youth Overweight Collaborative has been working with 12 sites throughout Maine.  The Healthy Care for Healthy Kids Collaborative in Massachusetts, 20 sites.  Well actually, the Maine Youth Overweight Collaborative has now 20 sites, that’s throughout the state of Maine.  High Five for Kids is intervention study that we’re doing with folks at the Medical School at Harvard.

And here’s the poster that they have for the Maine Youth Overweight Collaborative.  It’s called Keep Maine or Keep Me Healthy.  They have these very simple goals, 5-2-1-0.  Again, this 5-2-1--the 5-2-1 actually--logo was first created by Blue Cross Blue Shield of Massachusetts and spread throughout the state and other states are picking this up.  I think in Delaware they call it 5-2-1 Almost None, in Chicago, Clock Went 5-4-3-2-1.  They didn’t want to talk about zeroes so they’ll talk about four waters, three dairies per day.  Very simple message focused on a few behavioral targets, but now rather than just schools presenting this information to kids and parents, you have the clinicians, the primary care practice sites bringing this up with parents, talking about them and the same thing as I said in preschool settings.  We’ve been doing now some really fun work with the city of Boston.  This is on really the energy expenditure side to really identify opportunities for kids throughout the city of Boston to engage in physical activity and sports and after-school play and having safe playgrounds.  And actually, our one study, which actually our mayor presented this at our press conference a couple of years ago showing just dramatic disparities across parts of the city and safe place basis and the prevalence of recreational facilities.  The later color areas are some of the poorer areas of Boston and they have the fewest facilities.  We’ve been working with our local Boston staffs and they have taken the same 5-2-1 message and now start to apply it to adults.  It’s actually the first program I know of that started to focus on this two-message of television viewing among adults, which I think is a great idea.  Why hasn’t anybody spoken about that is because adults control the TV and they don’t want to give it up.  It’s just a thought.  We’ve been doing some really fun work with the YMCA of the USA called the Goulet Project.  My colleague, Jean Wiecha leads this and it’s focused on implementing within after-school programs all throughout the country, the same messages.

So finally my vision for really ending the obesity epidemic and eliminating disparities is that we really need to keep on developing interventions and there’s a lot of work going on all over the country.  I tended to talk about our work but there’s lots of great stuff happening.  We need to develop these interventions grounded in science that effectively provide support of environments for healthy eating and physical activity for children and adults.  But of course unless this is translated into action, into the diverse lives of households and children and youth and via a multitude of channels, so it’s reinforced.  So if you, as a mom, limit the TV viewing of your kids that they don’t just run next door where there are no limits, which is what happens of course with my kids.  We have to reinforce this and provide support to families throughout the life course, and I think then we can make a difference and I hope we can.  So thank you.