Transcript Are Current Health Care Practices Propagating Obesity in
Are Current Health Care Practices Propagating Obesity in our Youth?
The Role of the Physician to Prescribe Solutions
Thomas M. Best, MD, PhD, FACSM
The Ohio State University Improving People ’ s Lives through innovations in personalized health care Sports Medicine
What Motivates Change?
• • • • • There is a crisis A critical mass of scientific evidence exists Shift in social attitude occurs Public cynicism grows Political pressures begin to build
What Motivates Change?
• There are 2 kinds of disease; one is pathological, the other is political
Physical Exercise offers protection against a cluster of diseases
Type 2 diabetes Cardiovascular Diseases Breast cancer Colon cancer Pedersen BK. J.Physiology 2009 Dementia Depression
Exercise Deficit Disorder (EDD) in Youth
• Walker GA, Edwards NM, Stracciolini A, Faigenbaum AD, Myer GD. The Use of Exercise-specific V Codes and Reimbursement at a Large Pediatric Medical Center. AMSSM 2013.
Comprehensive Management Strategies for Management of EDD in Youth Myer, GD, Faigenbaum, AD, Stracciolini, A, Hewett, TE, Micheli, LJ and Best, TM (2013). "Comprehensive Management Strategies for Physical Inactivity in Youth." Current Sports Medicine Reports July/August.
Lecture Overview
• • • • Discuss the paradox that exists in youth fitness and sports today. Review the wide ranging benefits of PA in kids and implications of an inactive youth population.
Talk about current messaging on youth health behaviors Discuss the role of the physician and healthcare systems in assessing and prescribing exercise.
Youth Fitness and Sports Paradox
• • Survey of HS seniors: – Less than 25% of boys and 15% of girls exercise vigorously .
– Childhood obesity is an emerging epidemic.
However; – Half the exercising group is actively involved on an athletic team, many participating all year.
– Increased risk for orthopedic injury, especially related to overuse.
Youth Fitness and Sports Paradox
• The Changing Landscape of Playgrounds!
– Most exercise obtained by children in America is no longer obtained in physical education class or free play; it comes through organized youth sports.
– Children are less fit and obesity is growing, yet so is athletic injury!
Physically Inactive kids at greater risk for injury!
• • • Study of 995 children aged 9-12 years.
– Low levels of habitual PA have significantly increased injury risk.
The children at highest injury risk are the target audience of the contemporary PA promotion efforts.
Therefore, PA promotion should focus on injury prevention as well.
Bloemers BJSM 2011
Benefits of Physical Activity in Kids
Why Kids Should Exercise
• Compared to kids who don’t exercise, kids who do: – Can run longer and faster – Have stronger bones – Have stronger muscles – Are less likely to be fat – Have less stress and depression – Are less likely to develop chronic diseases – Are more likely to be healthy adults
Exercise Helps Prevent:
• • • • • • • • Diabetes Cancer (breast and colon) High blood pressure Depression Osteoporosis Alzheimer’s disease Heart attacks Dying early
Physical Activity Improves Mental Health
• • • • Regular PA may increase self esteem Regular PA may decrease anxiety/depression* Some evidence shows teen girls have lower rates of sexual activity and pregnancy when PA increased Some evidence regular PA associated with decreased smoking, alcohol and drug abuse
K.J. Calfas, W.C. Taylor. Ped Exerc Sci 1994. 6:406-423 Sabo et al. J Adolesc Health 1999;25:207-16
Fitness And Stanford Achievement Test 9
th
Ed
SAT-9 and Fitnessgram Results • Fitnessgram test: – 1. Aerobic Capacity – 2. Body Composition (% of body fat) – 3. Abdominal Strength and Endurance – 4. Trunk Strength and Flexibility – 5. Upper Body Strength and Endurance – 6. Overall Flexibility
Grade 5
SAT 9 and Physical Fitness 353,000 Students 80 70 60 50 40 30 20 29 36 Reading 32 40 Mathematics 36 45 40 50 46 10 0 1 2 3 4 Number of Fitness Standards Achieved 5 Source: California Dept. of Education Study, December 10, 2002 58 55 6 71
Grade 7
SAT 9 and Physical Fitness 322,000 Students 70 60 50 40 30 20 10 26 28 Reading 31 32 Mathematics 34 36 41 44 50 54 0 1 2 3 4 Number of Fitness Standards Achieved 5 Source: California Dept. of Education Study, December 10, 2002 60 66 6
Grade 9
SAT 9 and Physical Fitness 279,000 Students 70 60 50 40 30 20 10 21 35 Reading 24 38 Mathematics 28 43 31 51 37 0 1 2 3 4 Number of Fitness Standards Achieved 5 Source: California Dept. of Education Study, December 10, 2002 58 45 6 67
Socioeconomic Status** & Number of Fitness Standards 2004 CST* Scores in English- Grade 5 380 370 360 371,198 Students (203,726 NSLP and 167,472 Non-NSLP) Non-NSLP NSLP 350 340 330 320 310 300 0 1 2 3 4 Number of Fitness Standards Achieved *California Standards Test **National School Lunch Program Results using math scores were consistent with those using English-Language Arts scores. Results for seventh- and ninth-grade students were consistent with those for fifth graders.
Source: California Physical Fitness Test, 2004 Results, Calif. Dept. of Ed., April 2005 5 6
Improvements in Fitnessgram Results
PE 4 Life Program at 6 months Modified Sit & Reach Push-Up Paced Curl-Up Pacer Test (Cardiovascular Fitness) Flexibility Test Strength Test Woodland Elementary School, Kansas City PSD Fall 2005 – Spring 2006, Grades 4 and 5 13.5 % 16.5 % 21.6 % Fall 2005 Spring 2006 31.1 % 12.4 % 28.1 % 19.4 % 59.6 % 4.5 % 12.7 % 3 % 16 % 60% 88% 127% 207% 182% 433% 0% 10% 20% 30% 40% 50% 60% 70%
Percent Reduction in Disciplinary Issues PE 4 Life Program at 6 months Woodland Elementary School, Kansas City PSD #33 Fall 2005 – Spring 2006, Grades 4 and 5 Discipline Incidents Involving Violence 94 228 2004 - 2005 2005 - 2006 59% Resulting Out-of-School Suspension Days 0 392 1177 200 400 600 800 1000 1200 1400 67%
Fitness and Neurocognitive Function in Preadolescent Children • • • • 24 children, mean age, 9.6 years Fitness assessed by FITNESSGRAM Neurocognitive function assessed by responses to a stimulus discrimination task Fitness was positively associated with attention, working memory, response speed, and cognitive processing speed Hillman CH et al. Med Sci Sports Exerc 2005; 37:1967
How Much Physical Activity Do Kids Need?
• •
Children and adolescents should do 60 minutes (1 hour) or more of physical activity daily.
– Aerobic Activities: most should be either moderate or vigorous intensity PA. Include vigorous-intensity PA at least 3 days per week.
– Muscle-strengthening Activities: at least 3 days of the week, as part of the 60 or more minutes. – Bone-strengthening Activities: on at least 3 days of the week, as part of the 60 or more minutes.
Activities should be age-appropriate, enjoyable, and offer variety.
Kids exercise less as they get older
Boys weekday 14.7 yrs Girls weekend 12.6 yrs
JAMA. 2008;300(3):295-305. doi:10.1001/jama.300.3.295
% of High School Students Meeting Guidelines
100 80 60 40 20 23.7
17.1
18.5
15.5
14.9
10.5
0 Total Female Male White Black Hispanic
* Were physically active doing any kind of physical activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day during the 7 days before the survey.
Source: National Youth Risk Behavior Survey, 2007.
When are elementary school students active?
8000 7000 6000 5000 4000 3000 2000 1000 0 P.E.
School Day Outside School Boys Girls
Morgan CF, et al (2003) Journal of Physical Education Recreation and Dance, 74(7), 33-38.
NHANES
Prevalence of Overweight Youth Ages 2-19
Chronic Disease in Children
•
Pediatrics; Nov 08’
Number of children taking meds for chronic diseases jumped dramatically in past 3 years.
– Diabetes 103% increase (kids as young as 5) – Asthma 47% increase – ADHD 41% increase – Cholesterol 15% increase
Where will we find our future?
• • • • • • Firemen Police officers Prison guards Soldiers Lifeguards Construction workers
“The Freshman 15?”
• • Studies suggest actual weight gain during 1 st year of college is: – ~6 lbs in men – ~4.5 lbs in women.
What are the causes?
– Not enough exercise.
– Poor diet – fast food, dormitory food, skipped meals.
– Poor sleep habits – Stress.
Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI
30, or about 30 lbs. overweight for 5’4” person) 1990 2000 2010 No Data <10% 10% – 14% 15% – 19% 20% – 24% 25% –29% ≥30%
Obesity Hysteria
• • • • • The world has now been sufficiently alerted to the global problem of obesity.
Patients have been labeled and stigmatized.
Assigned lots of blame.
Spent lots of money.
…and gotten nowhere.
Are patients and their physicians giving up?
• • • Data from National Ambulatory Medical Care Survey for 1995-96’ and 2007-08’ showed: – During this period, adults who were overweight or obese increased from 52.1% in 95’ to 63.3% in 08”.
– Patients seen in 2007-08; had 46% lower odds of receiving weight counseling than 95-96’.
– Patients with hypertension 46% less likely and diabetics 59% less likely to receive counseling.
The campaign on obesity is not working!
What’s the definition of insanity?
Kraschnewski, et al, Medical Care, 2013
We need a new (and fresh) approach!
• • • We need to give patients permission to be fat; And still be healthy!
Shift focus off of BMI and onto physical activity.
Health At Every Size (HAES) – Focus on broader health.
– 95% regain lost wt. in 3-5 yrs.
– Change in BMI is not a success measure for an exercise program.
Death Rates by Fitness & BMI Categories
70 60 50 40 30 Low fit Mod fit High fit 20 10 0 <27 27-30
Normal Overweight
Barlow et al. Int J Obes 1995; 19:Suppl 4, S41-4 >30
Obese
after adjustment for health status, smoking, glucose, cholesterol, & BP
What can we do?
• • • • Large scale exercise prescription initiative in adults and kids: – Every patient; Every visit; Every treatment plan.
Physical activity should be recorded as a vital sign and kids encouraged to do 60 min of exercise per day.
Message should be the same from every medical provider.
We must begin to merge fitness with healthcare.
Smith, Johnny 12 yrs M
What Can Busy Physicians Do to Encourage Physical Activity?
0 Minutes:
Running late? Too many other concerns on the patient’s list? Relax. Perhaps you can discuss physical activity at next visit. Hopefully office staff will have assessed exercise and provided resources .
1 Minute for Advice:
Quickly congratulate kids (and their parents) who are getting 420 minutes or more per week of moderate vigorous physical activity. Advise patients who are getting fewer than 420 minutes of the importance of physical activity, especially linking benefits to the child’s complaints, problems and health risks.
What Can Busy Physicians Do to Encourage Physical Activity?
2 Minutes for a Prescription:
Review key messages about the importance of physical activity.
Offer a generic Exercise Prescription.
Suggest useful ideas (e.g. walk to school, bike transportation, active games, after-school activity, family fitness activities).
5 Minutes for Brief Counseling:
Assess readiness for change regarding exercise habits.
Ask what the child might want to do to be more active and barriers to prevent this from happening -- brainstorm on how to get around them.
Explain to parents in detail how exercise affects health and development and their child can go about incorporating it into their life.
EVS in Kids; Kaiser Permanente
• • Days per week in 153,746 kids age 12-17 (year ending 1/31/13): – 15.2% report 0 days per week.
– 15.7% report 1-4 days per week.
– 69.1% report 5 or more days/wk.
Percent reporting >150 min mod exercise per week: – 77.5% in 12-17 yrs.
– 34.5% in 18-64 yrs.
– 29.8% in 65+ yrs.
“At Kaiser Permanente, we want you to Live Well, Be Well and THRIVE!”
Kaiser Permanente – “Kid Wisdom”
Summary
• • • • Youth sports/activity paradox – kids are doing too much or too little.
The wide ranging benefits of PA in kids and adults are well established.
We need to encourage kids to be Healthy at Every Size by engaging in regular PA.
Physician have an important role to play in promoting PA for health – An Exercise Vital Sign is an easy way to bring a discussion on PA into the exam room.
– Even brief advice can have a significant affect.
A Call-to-Action
• • • • • • • • • • • Mississippi State U of Arizona Georgia Tech Lewis & Clark College U of South Florida Joliet College Kentucky Wesleyan Roanoke College UCCS Penn State Slippery Rock