Overweight/Obesity: Weighty Issues for the

MCH Population

Jamie Stang: Good morning. I’m going to be providing an overview today, and I think, actually, even though we’ve switched the order, it will probably set the stage well for the next two presentations. Just to give you a little bit of background. I’m sure this is review for most of people, but it’s always helpful, I think, to have it in. When we talk about obesity, generally, we’re talking about excessive body fat. However, with children and adolescents, we use BMI as a screening tool. When we talk about obesity and overweight in youth, I think one of the pieces that probably makes it the challenge that it is, is how multi-factorial it is. It’s not just individual factors. It’s family factors, it’s society, it’s populations, and as I talk today, I hope you will see how intertwined these really are. I also want to start by saying that one of the biggest misconceptions that I see, whether it’s when I’m reviewing papers for peer review journals, or when I’m review grants, is the fact that people confuse the BMI cut-points of adults with children. The BMI cut-points for adults are 25 and above is overweight. And 30 and above is obese. For children and adolescents, that’s not at all appropriate. There are age differences, there are gender differences, and it may be a cut-point of 18 or 19 that is really the defining cut-point for overweight for some youth. And so I think it’s always imperative to remind people that when we’re talking about youth we’re talking about age and gender specific cut-points based on percentiles and not using the adult BMI cut—points. Now, as an epidemiologist, I always like to show trend data, and I’m very interesting in numbers and this graph gives you a little bit of information about what we’ve really seen among the adult U.S. population. And I know some people get tired of the word “epidemic” used with obesity, but when you’re talking about 65% of the population, it certainly does qualify as an epidemic in terms of overweight or obesity. Almost 31% of the adult population at this point in time has the BMI of 30 or above, which classifies them as obese. And when we see it in adults, it’s mirrored in children. Basically, I always say that children live in families, families live in communities, communities are part of a population. And certainly we see the same trends in adult obesity that we do in child and adolescent obesity and overweight. You can see the data here, that within the course of approximately a little more than one decade, we have seen dramatic increases in the prevalence of overweight and at-risk for overweight, and as some people might say, overweight and obesity. Obesity being above the 95^th percentile, which I actually call overweight, and then at-risk of overweight, being above the 85^th percentile, which some groups choose to call overweight. Now what I think is actually more important in terms of the health care system is not just the sheer numbers, I mean, obviously, as an epidemiologist, the sheer numbers are of interest. But the fact that the overweight adults and children are not just more numerous, but they’re significantly more overweight. And trend data from the N. Haynes study has shown that more and more of the children have the very significant obesity or overweight as do adults. Obesity has grown faster than overweight in terms of prevalence in this country. What that means is, for the health care system, and for prevention, is that right now we’re at a very critical juncture, because not only do we have to meet the needs of a larger percentage of the population, but they are more medically at risk for the many of the complications, and that is a tremendous burden on the health care system. With persistence of overweight, there are really mixed data, but in general, as age increases, persistence increases, so you go from a persistence of about 15% in infancy that will persist overweight into adulthood, up to more than 80% by the time a child reaches puberty at that point in adolescence. And so certainly, the longer that we allow a child to remain at risk of overweight or overweight, the less chance we have of really intervening significantly, and the more likely they are to persist into adulthood. As the degree of obesity increases, the persistence increases, and then if a child has one or more parents that are overweight, they are more likely to be overweight into adulthood. Now, is that genetics, or is that environment? I don’t know that we really have a way to ferret those two out. It really is so intertwined that a few of the, and I’ll show you the data in a minute, have tried to do that, but we don’t get particularly good estimates. Now I talked a little bit ago about one of the problems being that children are more overweight, and adults are more overweight. And this is data from youth that are from five to 17 years of age. This was done by Freeman as part of a cohort study. And what they found is, when you actually take 5- to 17-year-old children, who are overweight, a relative risk of one, is actually a relative risk more than an odds ratio, of one would be the non-overweight child, you can see that risk factors for cardiovascular disease increase anywhere from two-fold to seven-fold. Whether we’re talking about a two-and-a-half times the risk of having high cholesterol, or elevated diastolic blood pressure, up to seven times the risk for having elevated triglycerides. And what I think is a particularly daunting number is the last number on this slide, which is the elevated insulin levels, which are indicative of impending Type II diabetes, the insulin-resistance, at about 13 times the risk compared to non-overweight youth. And again, remember that these are children as young as five and up through 17. And then, adding to that, is that not only do these children tend to have one risk factor, but they often have clustering risk factors. So in the same dataset, when they looked at overweight children versus children that were below the 85^th percentile, you can see that about a quarter of all children in the population had a risk factor for CVD, but when they just isolated the overweight children, it was about 61%. When they looked at children that had two or more risk factors, the general population was about seven percent, and among the overweight children, it was more than a quarter. So certainly, it is not just a cosmetic issue as some people would have us believe, but we’re just focused on trying to make everyone look the same, it really truly is about quality of life and about future health care needs. Now, in the interest of time, I won’t go through a lot of this data, but there are psycho-social consequences as well, that need to be kept in mind, whether we’re talking about discrimination, whether we’re talking about increased risk of depression, and other issues, and then certainly eating disorders. So there are a whole body of risk factors that go along with overweight and obesity. There is data, emerging data, on some of the costs that’s associated with treating this disorder. These are national hospital discharge survey data, and you can see that they took data from 1979 to 1999, so in a 20-year period, they showed increases in many of the primary and secondary diagnoses related to obesity. They showed increases in hospital stay, which I find interesting, because I know when I had my son, I was about of the hospital within 30 hours. They seem to shorten the stay for many health care issues, but obesity is actually been associated with longer hospital stays, and then more than a tripling in terms of what the cost is for treating or dealing with obesity and overweight associated illnesses. So why is this happening? Well, if I had the answers, I would probably be out on a yacht somewhere in the middle of the ocean and not here this morning. I think that, you know, people very simplistically say it’s because we’re taking in more calories than we’re burning up. And in terms of a very easy equation, yes, that’s true, but as I mentioned at the beginning, there are so many factors that play into this, that it’s not really that simple. Dr. Leslie Leidel, who’s a colleague of mine at the University of Minnesota, and I have talked about sort of the ideology continuum, where, and really, if I was better technologically, I would have made this a circle so that you could really see how intertwined it is, but I’m kind of stuck with straight lines, at least for now. Starting with personal responsibilities, the very individual factors that affect each person as an individual, going to the interpersonal factors, which are things like family, and peer groups, and culture, going further down the continuum to the community, which really encompasses the schools, the environment that these children and adults live in, and then to the population factors, which are really national or international. And I’ll give you a very brief overview. This is actually about a four-hour presentation condensed to 20 minutes, so it’s really brief of some of these factors. But genetic and endocrine factors are, I think, rather interesting and there’s a lot of interest in this right now, when they’ve done the studies that I think are going to come the closest to determining exactly what is genetic, and what is environmental, when they’ve done twin studies of twins that were raised apart, they’ve found anywhere from a 25 to a 60% hereditability, basically, of body weight and body fat distribution. So if you pick kind of a midpoint of about 40% that really means that we have a tremendous ability, about a 60% variation there that we can deal with in terms of individual and environmental factors. And I won’t go through a lot of the genetic pathways and things today. There’s also a growing body of interest in what’s called the fetal origins hypothesis, which basically, there are whole conferences on this topic, but looking at intrauterine factors, and the fact that women who particularly, most consistently in the studies have low calorie and energy intakes in the first 22 to 25 weeks of pregnancy, those infants go on to have much higher rates of obesity and cardiovascular disease later in life. Now part of that, if you think of it from sort of a physiological standpoint, it makes sense. There’s a lot of programming going on, basically hormonal endocrine development going on in the fetus during that period. And so this is an area where we can’t intervene a lot with the exception of what we can do during pregnancy, but in the case of families and things, we do look at this as an individual factor. Now the personal factors, such as knowledge or culture have been looked at, but when you look at teens, in particular, and children, there are very few, if any, differences, between the knowledge levels of overweight children and non-overweight children in terms of nutrition knowledge, or physical activity knowledge. It’s just not a big factor. Culture does play some role. And if you look at data from the ad-health study of adolescence, you will find some of the data from Barry Popkin and others, where the longer a family has been in the U.S., the more culturated the adolescent is, the more likely they are to be overweight, and there’s a doubling or tripling within one to two generations of living in the U.S. So certainly, a culturation, and something about particular aspects of our western culture, seem to pre-dispose youth to obesity. Parental and family influences are really a large topic, and this is a topic that I’m particularly interested in. Things like family eating and activity behaviors and attitudes, family role modeling, I’ll show you some data, just brief data in a minute, parenting style and consistency, particularly around physical activity and nutrition, and then roles delineation of food choices. Really, who does make the food choices in the family. Well, again, this is data from Leslie Leidel, one of my colleagues. They did a parental energy index, where they asked parents of children who were middle school and early adolescence how often do you talk about various health issues with your child? And you can see that eating habits and physical activity come out at the bottom of the list. They’re 9 and 10. Parents really get tired of dealing with this issue. They deal, start dealing with it in toddler-hood with the picky eating, and by the time a child is six or seven, they lose a lot of control, they feel they lose a lot of control over the eating habits of children, and so it’s an issue that drops down. There are more immediate issues to talk about. And so this is one of the things that we’re faced with, in terms of dealing with these issues, is that how do we get parents to spend more time on this, and make them feel more confident about addressing these issues with their children. And then, who determines what’s eaten? Sort of the whole role delineation piece. Well, children and adolescents have a tremendous influence on what goes on within their household. They make anywhere from half to three-quarters of the restaurant choices of where families eat, and they actually determine a third of the actual name-brands of foods that are purchased. Parents are three times more likely to say that their children are the influential force in restaurants and snack foods than they are to name themselves. So there’s a real shift in role delineation that’s occurred in a couple of generations that I think really needs to be addressed when we talk about family, the interpersonal and the community aspects. And then this is relatively new data. There are some studies out of Germany and Japan that have looked at various factors. You can see the pink factors are protective factors basically sleeping more than 10 hours a night is protective against overweight, high level of parental education. When we look at the risk factors, they come out as a high BMI for parents, high birth weight, high growth weight in the first year of life watching TV or video games more than an hour per day, and snacking while watching TV. Well, what really struck me when I started reading these studies was the fact that I don’t think it’s so much the sleep, which is what the media really focused on, that children who sleep more are less likely to be overweight. I think it points to parenting, and a certain type of parenting style that’s less permissive. Parents that have set rules and consistently enforce rules around issues of eating, physical activity, sleep, media use, etcetera. Frequency of family dinner basically, children are eating less and less with their family. So to some extent, they’re making more of their own food choices, particularly as they get into the teen years. Now, there are some community and cultural factors to consider. Food venues are one. And it’s really important, I think, to keep in mind the whole pricing strategy. Teens are very economically savvy. They want to spend their money wisely. And they have a lot of money, and marketers know it. And they price the food so that it’s much more economical to buy the larger size. A friend of mine who has teenage boys, they went out and bought a two-liter bottle of soda. She gave them a dollar to go into a store, and instead of coming out with a can, they came out with a two-liter bottle, because, look, for 11 cents more, you can get the whole bottle. And they really know that this is something that they can reach youth with. Unsafe neighborhoods, lack of non-competitive physical activity. Overweight children will tell you they do not like competitive activities. We need to find things that are safe and fun and are non-competitive. Portion sizes are an issue. Marketing of foods directly to children and adolescents within schools and within the media as a large, is an issue. And then really, talking about the normative size of portions. I don’t think people know what a true USDA portion size is any more. Because we’re become so accustomed to the large plates filled with food. So it comes down to what they call the toxic environment, which Kelly Brownell and Elizabeth 9Battle wrote, and to me, this is one of the quotes that really sums up our society up. It’s hard to envision an environment more effective than ours for producing nearly universal body dissatisfaction, preoccupation with eating and weight, and obesity. And this is my slide of the toxic environment. This is the Minnesota State Fair, about two years ago, when deep-fried candy bars were all the rage. And as if candy bars weren’t interesting enough on their own, we had to dip them in batter and deep fry them. And you can see the lines were long. And here is just an illustration of the food portion sizes, showing you the portions have gone up anywhere from doubled to more than quadrupled, within about a 50-year period. And so we really have become accustomed to much more food on our plates. I want to just touch briefly on some of the school issues and I know that’s going to be discussed later, but just telling you that when you look at the environment of youth, school is a big issue. And you look at data from the CDC ship study about 20% of schools require fresh fruits or vegetables on the ala carte line, but more than twice that number have soft drinks contracts with the schools. It’s a source of large revenue. Now I want to show you a picture of what we consider to be an ideal ala carte line. We’ve basically got fruits, vegetables, bagels, things that are really particularly good choices for the teens. These were intervention, these are slides from some of the intervention schools that we’ve worked in. But on the other hand, you’ve got three-quarters of high schools, two-thirds of middle schools, and half of elementary schools across the U.S. offering fast food types of ala carte menus. We’ve got 13% offering name brand foods, and I’ll show you a slide of that in a minute. And remember that ala carte foods do not have to meet the nutritional standards that the USDA reimbursable meals do. And this is what, if you haven’t been in a school cafeteria for awhile, this is what they’re starting to look like. Papa John’s, Colombo, very much the name brands so that the children not only get access to the food, but they become very loyal customers. My second-grader wants Domino’s pizza, because Domino’s brings pizza to the school every Wednesday, and they put their boxes up so that the kids can see what type of pizza they get. It’s very pervasive in our society. Vending machines are accessible by almost all high school students, about two-thirds of middle students and more than a quarter of elementary students. Again, they don’t have to meet nutritional standards. Now why are these things in our schools? Because the money that is gained from these is discretionary money. Charles Keight, who’s the head of the Minnesota School Administrator’s Association and I were talking and he said that is very coveted money by school administrators because they have total discretion as to what they do with these funds. And if we really want to fight the issue, we need to find a way to replace those funds so that school administrators can continue to support programs, but not have to do it with vending. And here, again, is the cafeteria at one of our intervention schools. Physical education requirements have come down and the percent of children who are enrolled in physical activity has decreased over time, so certainly, they have more access to higher calorie and energy-dense foods, and they have less physical activity during the day. Media is a particular issue, and you can look the first column is basically the 2- to 18-year-olds combined, and then it’s broken out. Children spend almost three hours a day watching television. And then you add that to the computer time, the video games, and it becomes a significant portion of their day. And as the data has pretty clearly shown, that the number of hours of television viewing as it goes up, obesity goes up. Now it’s not just sitting still that’s watching the media that’s the issue, it’s the advertising as well. They spend about $25 billion a year on advertising and promotions directly aimed at children and adolescents. And I can tell you we don’t have that kind of money to do our intervention studies. This is data from 1997, and you can see the USDA nutrition education budget is on the bottom. It’s about $300 million compared to almost $800 million that were spent just on breakfast cereals alone. And this does not include all of the fast food, the soft drinks, it’s just tremendous, the amount of influence that children are exposed to. Now how big a role should people you have, when in terms of fighting obesity? Well, a national study, this is out of the Harvard Forum on Health, you can see that the white bars are no role at all, and people really have, really look toward health care as the number one providers of services, basically, to work with this issue, then schools, then government, and employers last. And what would they support? Well, you can see that purple is strongly support, and the blue is somewhat support. Healthier school lunches and health education come out at the top. Limiting ads for unhealthy foods were still supported by more than half of adults, but it came out in the bottom of this pack. So I’ve left you with some strategies, and in the interest of time, I won’t go through these right now. I want to leave time for the other speakers, but basically we need to look toward anticipatory guidance and training for health care professionals. We need to look at minimum nutrition standards for school foods, and really working with getting the vending and the ala carte under control. Providing education to parents, and supporting community and statewide efforts that really encourage physical activity and healthful eating. And finally, the mass media. We really need to find a way to address what is being given to our children through mass media and advertising. So with that, I leave you with another slide of the Minnesota State Fair, and hope that one day the line in front of the fresh veggie pie will be as long as the line in front of the deep fried cheese curds. So, I will.