Obesity Prevention and Education for School Nurses

The planning committee & faculty attest that no relevant financial, professional or personal conflict of interest exists, nor was sponsorship of commercial support obtained, in the preparation or presentation of this educational activity.

Objectives

• • • • • • • •

Define obesity and relate current trends in Arkansas and in the US.

Discuss risk factors for childhood obesity.

Explain health consequences of obesity.

Describe importance of health assessment especially blood pressure monitoring in regards to childhood obesity.

Explain the relationship between Acanthosis nigricans and obesity. Describe the process for appropriate height and weight measurement for children.

Review pertinent legislation. List resources available for schools and school nurses to combat childhood obesity.

Obesity Trends

Definition of Obesity

Obesity is defined as an increased body weight in relation to height, when compared to some standard of acceptable or desirable weight.

Obesity / Overweight in Children

• Obesity in children / youth refers to age and gender- specific BMI that is equal to or greater than the 95

th

percentile of the CDC BMI charts •

Overweight/at risk for obesity

between 85

th – 94 th

percentile (IOM, 2007)

In the Past Three Decades…

Number of overweight: • 6-11 year olds tripled • Adolescents tripled (Gerberding & Marks, 2004) • Overweight adults tripled (>60%)

Obesity in Children

16.3% of children and adolescents ages 2 -19 years are obese • 11% considered extremely obese • 12.4% • 17.4%

2 - 5 year old 6-11 year olds

• 17.6%

12-19 year olds 31.9% are overweight / obese (Ogden, JAMA, 2008)

Obesity in the United States

http://www.cdc.gov/obesity/data/trends.html

2009

Trends in Obesity Among Boys

Trends on Obesity Among Girls

• •

The Epidemic of Childhood Overweight and Obesity

 9 million children >6 yrs obese (IOM, 2005)  25 million children / adolescents are obese or overweight (NHANES, 2007) » Males 18.2% » Females 16.0 % • HHS estimates that 20% of children / youth in the US will be obese by 2010.

(GAO-07-260R Childhood Obesity and Physical Activity) http://www.gao.gov/new.items/d07260r.pdf

Risk Factors for Obesity



Risk Factors for Obesity: Diet



Inactivity

– High-calorie foods – High-fat foods dense in calories – Sedentary kids more likely to gain weight – Soft drinks, candy, desserts high in sugar / calories – Inactive leisure activities

Risk Factors for Obesity:



Genetics

• Overweight family and child may be genetically predisposed to gain excess weight • environment of high-calorie foods • physical activity may not be encouraged

Heredity… / Genes

• • • 

80%

of children with two overweight parents will become overweight 

40%

of children with one overweight parent will become overweight 

7–9%

of children with no overweight parents will become overweight http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.htm

Percentage of Overweight Children and Youth Who Become Overweight Adults 80 70 60 50 40 30 20 10 Preschool School-age Adolescent 0 Percentage

(National Institute for Health Care Management, Nov 2003)

Risk Factors for Obesity:



Psychological

• Some eat to cope with problems or deal with emotions; stress or boredom – Parents may have similar tendencies

Environmental / Media Temptation at Every Turn

• Chips, cookies, and other less healthy food choices are marketed to children via media.

Behavioral/Socio-cultural

• • • • • Sedentary lifestyles  Calorie-dense foods  Large portion sizes  Excessive television viewing / video games  low energy expenditure Parent modeling - eating and exercise behaviors

Consequences of Obesity

Health Consequences: Adult Premature Death

• 500,000 deaths per year – surpassing tobacco • Risk increases with increased weight (USDHHS, 2001)

• • •

Health Consequence: Children Risk of CVD

Hypertension Elevated insulin levels Dyslipidemia – Elevated low density lipoprotein (LDL) – Abnormal triglyceride levels

Other Health Consequences Children

• • • Sleep apnea Asthma Risk for Kidney problems • Gastrointestinal – fatty liver disease – elevated liver enzymes – gallstones and cholecystitis – gastroesophageal reflux – constipation

Other Health Consequences Children

• • Endocrine disorders – T2DM – Polycystic Ovary Syndrome – Early sexual maturation Orthopedic disorders • Skin conditions • AN – seen in:  10% of obese white children  50% of obese black children • Skin fungal infections

Health Consequences: Psychosocial !!! Children

• Depression/Anxiety • Quality of Life • Negative self-esteem/Poor body image • Feelings of chronic rejection / Withdrawal from interaction with peers/Behavioral problems • Decreased endurance / involvement • Social, academic and job discrimination (Deckelbaum and Williams, 2001)

Health Consequences for Children – Risk of T2DM

• Clearly, the growth in the treatment of type 2 diabetes could signal the beginning of a multitude of long-term healthcare needs for many of these children.

Economic Burden of Obesity

T he Economic Estimates of the impact of obesity are astronomical:

• 1995 - Approximately $52 billion was attributed to obesity • 2003 - This figure had increased to $75 billion (CDC, J. Gerberling, 2005) According to one estimate total health care spending for children who receive a diagnosis of obesity is approximately $750 million a year http://www.medstat.com/pdfs/childhood_obesity.pdf

Economic Burden of Obesity

• • Obesity is the No. 1 driver of increasing health care costs in the US today Diabetes contributes to health care disparities in the United States

Recap: Rising obesity rates - result of a

• • • •

number of trends in the US

Americans consume 300 • Parks & recreation spaces more calories/ day than they did 25 years ago & eat less nutritious foods are not considered safe or well maintained in many communities Nutritious foods are…more expensive than calorie dense, less nutritious foods Americans walk less / drive more -- even for trips of less than one mile Adults often work longer hours & commute farther • • Many school lunches do not meet nutrition standards -children engage in less physical activity in school ↑ screen time (TV, video games) contributes to ↓ activity…for children (F as in Fat, 2009)

Assessing the Overweight/Obese Child

Assessment of the Overweight and Obese Child and Adolescent

• • • • • Hypertension Acanthosis Nigricans Nutrition and Physical Activity Child and Family History Height/Weight/BMI

Definition of Hypertension

Average Systolic blood pressure (SBP) [higher number] and/or diastolic blood pressure (DBP) the 95

th

[lower number] that is ≥ to percentile for gender, age and height on 3 or more occasions

Definition of Pre-Hypertension

Average SBP or DBP levels that are greater than or equal to the 90

th

less than the 95

th

percentile, but percentile Adolescents with BP levels greater than or equal to 120/80 mmHg should be considered pre-hypertensive http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

Assessing for Hypertension in Children & Adolescents

Approximately 9-13% of overweight children have elevated blood pressure Approximately 30% of obese children (BMI >95th percentile) have hypertension

Blood Pressure in Children Lower than an Adult – Normal Blood Pressures

• • • • • • • 4 91/52 6 94/56 7 96/57 8 98/58 9 100/59 10 100/60 11 102/61 • 12 104/62 • 13 106/63 • 14 107/64 • 15 109/65 • 16 110/66 • 17 110/66 (Selekman, 2006)

Hypertension Overview

New national data added to the childhood BP database Updated BP tables now include the 50 th , 90 th , 95 th , and 99 th percentiles by gender, age and height http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

Blood Pressure Levels for Boys by Age and Height Percentile Age Year 12 BP % tile 50 th 90 th 95 th 99 th SBP (mmHg) Percentile of Height 5 th 102 116 119 127 10 th 103 116 120 127 25 th 104 117 121 128 50 th 105 119 123 130 75 th 107 120 124 131 90 th 108 121 125 132 95 th 109 122 126 133 DBP (mmHg) Percentile of Height 5 th 61 75 79 86 10 th 61 75 79 86 25 th 61 75 79 87 50 th 62 76 80 88 75 th 63 77 81 88 90 th 64 78 82 89 95 th 64 78 82 90 http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

Blood Pressure Levels for Girls by Age and Height Percentile

Age Year 12 BP SBP (mmHg) Percentile of Height % tile 50 th 90 th 95 th 99 th 5 th 101 115 119 126 10 th 102 116 120 127 25 th 104 118 122 129 50 th 106 120 123 131 75 th 108 121 125 133 90 th 109 123 127 134 95 th 110 123 127 135 DBP (mmHg) Percentile of Height 5 th 59 74 78 86 10 th 60 75 79 87 25 th 61 75 80 88 50 th 62 76 81 89 75 th 63 77 82 90 90 th 63 78 82 90 95 th 64 79 83 91 http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

How To Use The BP Tables

1. Use the standard height charts to determine the height percentile 2. Measure & record the child’s SBP and DBP 3. Use correct gender table for SBP and DBP 4. Find child’s age on the left side of the table Follow the age row horizontally across the table to the intersection of the line for the height percentile (vertical column) http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

How To Use The BP Tables

5. For SBP percentiles in the left columns and for DBP %tiles in the right columns: – Normal BP = < 90 th percentile – – Pre-hypertension = BP between the 90 percentile or > 120/80 mmHg Hypertension = BP  measurement 95 th th - 94 in adolescents th percentile on repeated http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

How To Use The BP Tables

6. BP > 90 th percentile should be repeated twice at the same office visit 7. BP > 95 th percentile should be staged : – Stage 1 = the 95 th 99 th percentile to the percentile plus 5 mmHg.

– Stage 2 = >99 th mmHg. percentile plus 5 http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

Blood pressure in children - exercises

• 1.Boy - 10 y.o. 95 th %tile for height – blood pressure 100/60 Blood pressure is  50 th percentile = normal

Age Year 10 BP % tile 50 th 90 th 95 th 99 th SBP (mmHg) Percentile of Height 5 th 97 111 115 122 10 th 98 112 116 123 25 th 100 114 117 125 50 th 102 115 119 127 75 th 103 117 121 128 90 th 105 119 122 130 95 th 106 119 123 130 DBP (mmHg) Percentile of Height 5 th 58 73 77 85 10 th 59 73 78 86 25 th 60 74 79 86 50 th 61 75 80 88 75 th 61 76 81 88 90 th 62 77 81 89 95 th 63 78 82 90

Blood pressure in children exercises

• 2. Boy - 12 y.o. 50% %tile for height – blood pressure116/70 Blood pressure is  90 th percentile = normal

Age Year 12 BP % tile 50 th 90 th 95 th 99 th SBP (mmHg) Percentile of Height 5 th 101 115 119 126 10 th 102 116 120 127 25 th 104 118 122 129 50 th 105 119 123 131 75 th 108 121 125 133 90 th 109 123 127 134 95 th 110 123 127 135 DBP (mmHg) Percentile of Height 5 th 59 74 78 86 10 th 60 75 79 87 25 th 61 75 80 88 50 th 62 76 81 89 75 th 63 77 82 90 90 th 63 78 82 90 95 th 64 79 83 91

•

Blood pressure in children -

3. Girl 9 y.o. 90 th 118/76

exercises

%tile for height – blood pressure Blood pressure >90 th %tile = prehypertension

Age Year 9 BP % tile 50 th 90 th 95 th 99 th SBP (mmHg) Percentile of Height 5 th 96 110 114 121 10 th 97 110 114 121 25 th 98 112 115 123 50 th 100 113 117 124 75 th 101 114 118 125 90 th 102 116 119 127 95 th 103 116 120 127 DBP (mmHg) Percentile of Height 5 th 58 72 76 83 10 th 58 72 76 83 25 th 58 72 76 84 50 th 59 73 77 84 75 th 60 74 78 85 90 th 61 75 95 th 61 75 79 86 79 87

Blood pressure in children - exercises

• 4. Girl 16 y.o. 25 th %tile for height – blood pressure 126/80 Blood pressure is >90 th %tile = prehypertension

Age Year 16 BP % tile 50 th 90 th 95 th 99 th SBP (mmHg) Percentile of Height 5 th 108 121 125 132 10 th 108 122 126 133 25 th 110 123 127 134 50 th 111 124 128 135 75 th 112 126 130 137 90 th 114 127 131 138 95 th 114 128 139 139 DBP (mmHg) Percentile of Height 5 th 64 78 82 90 10 th 64 78 82 90 25 th 65 79 83 90 50 th 66 80 84 91 75 th 66 81 85 92 90 th 67 81 95 th 68 82 85 93 86 93

Classification of Hypertension in Children and Adolescents

SBP or DBP Percentile Normal Prehypertension Stage 1 hypertension

< 90 th percentile 90 th percentile to < 95 th percentile, or if BP exceeds 120/80 even if below the 90 th percentile up to < 95 th percentile 95 th percentile to the 99 th percentile plus 5 mmHg

Stage 2 hypertension

>99 th percentile plus 5 mmHg http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

Classification of Hypertension in Children and Adolescents

Normal Pre-hypertension Stage 1 hypertension Frequency of BP Measurement

Recheck at next scheduled physical examination Recheck in 6 months Recheck in 1–2 weeks or sooner if the patient is symptomatic; if BP is persistently elevated on two additional occasions, evaluate or refer to source of care within 1 month

Stage 2 hypertension

Evaluate or refer to source of care within 1 week or immediately if the patient is symptomatic http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

Assessing for Hypertension in Children & Adolescents - recap

1.

2.

3.

4.

5.

6.

7.

 Choose appropriate cuff size Take in upper right arm Cuff should cover approx 2/3 of upper arm Cuff bladder should cover 80–100 % of the arm circumference Adolescent – adult cuff size Large adolescent - extra large cuff Student should sit for 3-5 minutes in a quiet environment before the BP is measured

Refer for BP above the 95 th systolic or diastolic percentile for either

Therapeutic Lifestyle Changes

• • • Weight reduction - primary therapy for obesity related hypertension. Prevention of excess weight gain can limit future increases in BP. Dietary modification strongly encouraged in children and adolescents with pre-hypertension and hypertension Physical activity can improve efforts at weight management and m ay prevent future increase in BP Family-based intervention improves success

Acanthosis nigricans type III associated with obesity, insulin resistant states and endocrinopathy

• • • Acanthosis nigricans is a disorder that may begin at any age Velvety thickening Gray to brown to black in body creases – Neck, armpits, groin – Darker skinned people have darker lesions http://www.aocd.org/skin/der matologic_diseases/acantho sis_nigrica.html

(James, et al 2005)

Acanthosis Nigricans (AN)

• About 90% of children with type 2 have dark shiny patches on the skin, most often found on the back of the neck ("dirty neck") and in axillary creases http://www.childrenwithdiabetes.com

• Most commonly found in Hispanics, Native Americans, African Americans, Asian American/Pacific Islanders (Jones and Ficca, 2007)

Acanthosis Nigricans (AN)

• • • Most commonly associated with obesity or polycystic ovarian disease in women Can occasionally be found in people who have more serious underlying health problems or taking certain medications Treatment of the underlying medical condition usually resolves the skin lesions

What can be done about AN?

• Acanthosis Nigricans is a marker that signals elevated insulin levels and a risk of developing type 2 diabetes and other conditions in the future • Taking immediate action may help delay or prevent the health conditions associated with high insulin levels

AN / T2DM = further evaluation

• The current research does not support that AN will lead to type 2 diabetes (Jones and Ficca, 2007, CDC, 2005) • Discuss findings with the student and family •

Refer the student to seek additional medical advice

(Jones and Ficca, 2007)

Typical Acanthosis Nigricans of the Neck

Typical Acanthosis Nigricans of the Axillae

Quick Weight, Activity, Variety, & Excess Survey (WAVE) for Children

Evaluate eating practices: • quantity • • • quality timing of food intake identify foods/patterns of eating that may lead to excessive calorie intake A means for a quick assessment of diet and activity and may be useful for some clinicians and children http://bms.brown.edu/nutrition/acrobat/wave.pdf

Physical Activity Assessment

Assess daily activity levels Include time spent on: exercise and activity sedentary behaviors, such as television, video viewing, and computer use

Quick Activity, Variety, & Excess Survey (WAVE) For Kids

www.mypyramid.gov

MyPyramid.gov

The Dietary Guidelines for Americans, 2005, gives science-based advice on food and physical activity choices for health MyPyramid Worksheet

Check how you did yesterday and set a goal to aim for tomorrow www.mypyramid.gov

 Increased thirst  Snoring  Exercise intolerance  Increased hunger  Acanthosis nigricans

Child History

 Increased urination  Fatigue  Blurred vision  Weight gain

Family History

Diabetes risk factors:

 Parent or sibling diagnosed with diabetes  Grandparent or aunt/uncle diagnosed with diabetes  Mother diagnosed with gestational diabetes

Higher-known risk groups:

  African American  Pacific Islander  Asian American Native American  Hispanic/Latino  < 60 minutes/day of physical play or activity  > 2 hrs of TV/computer/video game use/day

Family History

Family history of obesity & medical problems Several obesity-related medical conditions are familial Family history predicts type 2 diabetes mellitus or insulin resistance, and the prevalence of childhood diabetes.

Cardiovascular disease and cardiovascular disease risk factors - (hyperlipidemia and hypertension) are also more common when family history is positive.

Consider history regarding first- and second-degree relatives (Barlow, 2007)

Key Components of a Healthy Lifestyle Education/Counseling

• • • • • 60 minutes of physical activity every day Recommended # of cups of fruits/vegetables per day http://www.mypyramid.gov/ Limit high-fat / high-sugar food/drink Encourage water intake Limit “screen time” to less than 2 hours per day • • Provide counseling / educate students, families / school staff on the key components of a healthy lifestyle Provide written diabetes prevention materials in appropriate language(s) from the National Diabetes Education Program (NDEP) http://ndep.nih.gov/index.htm