Transcript Diabesity – Prevention and Treatment

I DARE YOU
Daniel E. Hale, MD
Professor of Pediatrics
Chief, Division of Pediatric Endocrinology and Diabetes
University of Texas Health Science Center at San Antonio
Five things to share with families
when you see an overweight child
(or an overweight parent).
I DARE YOU
1.
2.
3.
4.
5.
Turn off the
television
Children walk (run,
bike, hike, swim)
Water/low fat milk
are the only
beverages at home
Fast food is a 1
time per week treat
Fruits and
vegetables are the
only snacks
After the dare, Morton was never
again seen in school
How many hours of TV does the
typical American child watch?
A. 1 hour
B. 2 hours
C. 3 hours
D. 4 hours
Turn Off the Television - 1
• Children spend ~4 hours a day
watching television, DVDs and
videos.
• 68% of 8- to 18-year-olds have a
TV in their bedroom; 54% have a
DVD/VCR player, 37% have
cable/satellite TV, and 20% have
premium channels.
• In 63% of households, the TV is
"usually" on during meals.
Roberts DF, Foehr UG, Rideout V. Generation
M: media in the lives of 8-18 yearolds. Kaiser Family Foundation. March
2005
Turn Off the Television - 2
• In 53% of households of 7th- to 12thgraders, there are no rules about TV
watching.
• In 51% of households, the TV is on
"most" of the time.
• Kids with a TV in their bedroom spend an
~1.5 hours more per day watching TV
than kids without a TV in the bedroom.
Turn Off the Television - 3
• TV viewing is replacing preferred
activities in a childhood (like playing,
reading, doing homework or chores).
• Kids who spend more time watching TV
(both with and without parent and
siblings present) spend less time
interacting with family members.
Bickham DS, Rich M. Is television viewing associated
with social isolation? Roles of exposure time, viewing
context, and violent content. Arch Pediatr Adolesc
Med. 160:387-92, 2006.
Vandewater EA, Bickham DS, Lee JH. Time well spent?
Relating television use to children's free-time
activities. Pediatrics 117:e181-91, 2006.
Turn Off the Television - 4
• Excessive TV viewing contributes to poor
grades, sleep problems, behavior
problems, obesity, and risky behavior.
• Children' s programming may not teach
what parents say they want their children to
learn; shows are filled with stereotypes,
violent solutions to problems, and mean
behavior.
• On average, children see ~22,000 TV
commercials each year. This includes
many ads for unhealthy snack foods and
drinks.
American Academy of Pediatrics. Television—what
children see and learn. Available
at: http://www.aap.org
Turn Off the Television - 5
• Being awake with the TV on for >2hr/day is a
risk factor for being overweight at ages 3 and
4 ½ years.
• Weekend TV viewing in early childhood affects
body mass index in adulthood.
• The best predictors for being overweight
among 3- to 7-year-olds, are physical activity
and TV viewing. TV was a bigger factor than
diet. Inactivity and TV became stronger
predictors as the children aged.
Lumeng JC, Rahnama S, Appugliese D, Kaciroti N, Bradley RH. Television exposure and
overweight risk in preschoolers. Arch Pediatr Adolesc Med. 2006 Apr;160(4):417-22.
Viner RM, Cole TJ. Television viewing in early childhood predicts adult body mass index. J
Pediatr. 2005 Oct;147(4):429-35.
Jago R, Baranowski T, Baranowski JC, Thompson D, Greaves KA. BMI from 3-6 y of age is
predicted by TV viewing and physical activity, not diet. Int J Obes (Lond). 2005 Jun;29(6):55764.
Turn Off the Television - 6
• Children who watch TV are more likely to be inactive and
tend to snack while watching TV.
• Two-thirds of the 20,000 TV ads an average child sees
each year are for food; most are for high-sugar foods.
• All television shows replace physical activity.
• While watching TV, the metabolic rate often goes even
lower than during rest.
Klesges RC, Shelton ML, Klesges LM. Effects of television on
metabolic rate: potential implications for childhood obesity.
Pediatrics 91:281-6, 1991.
McGinnis JM, Gootman JA, Kraak VI, eds. Food marketing to children
and youth: threat or opportunity? Washington, D.C.: National
Academy Press; 2006.
Turn Off the Television - 7
• The food and beverage industry targets
children with their television marketing, which
may include commercials, product
placement, and character licensing. Most of
the products pushed on kids are high in total
calories, sugars, salt, and fat, and low in
nutrients.
• Recent studies have reported success in
reducing excess weight gain in
preadolescents by restricting TV viewing.
Caballero B. Obesity prevention in children: opportunities and
challenges. Int J Obes Relat Metab Disord 28 Suppl 3:S90-5,
2004.
No Apologies Necessary
(AAP Position Statement)
• Too much television can negatively affect
early brain development. This is especially
true at younger ages, when learning to talk
and play with others is so important.
• The AAP does not recommend television for
children age 2 or younger.
• For older children, the Academy
recommends no more than 1 to 2 hours per
day of educational, nonviolent programs
Marketing to Children
Tips For Parents (AAP)
1. Set limits
1 hour, 2 hours, only after supper and homework are completed
2. Plan your child's viewing
Make TV a “conscious” choice (no passive TV watching)
3. Watch TV with your child
TV in public, not private, space
4. Find the right message
Does the program reflect your views/values/behaviors
5. Help your child resist commercials
Ask your child about the “message” (You will be surprised)
http://www.aap.org/family/tv1.htm
Tips For Parents (AAP)
6. Look for quality children's videos
The Coalition for Quality Children's Media http://www.cqcm.org
7. Give other options
Coloring books, family games, a walk
8. Set a good example
Turn on the TV with a purpose
9. Express your views
If you do not approve of something, talk about it with your children!
10. Get more information
http://www.aap.org/family/tv1.htm
Children Walk
What are the US Surgeon General’s
recommendations for physical activity
for adults?
A. 1 hour per day, 6 days per week
B. 1 hour per day, 3 days per week
C. 20 minutes per day, 6 days per
week
D. 40 minutes per day, 7 days per
week
Walk - 1
• During the 7 days pre-survey, 77% of
children aged 9-13 participated in free-time
physical activity, and 39% participated in
organized physical activity.
• 36% of high school students had participated
in > 60 minutes per day of physical activity on
≥5 of the 7 days preceding the survey.
• Of these, 64% of high school students
participated in sufficient vigorous physical
activity, and 27% participated in sufficient
moderate physical activity.
• Participation in physical activity declines as
children get older.
Youth Behavioral Risk Survey, 2005
Walk - 2
Type of Activity
>60 min/day (1)
Daily PE
(2)
Girls
27.8%
29.0%
Boys
43.8%
37.1%
i.e., the major source of physical activity for most
children is at school
(1) Any activity that increased heart rate and made them breathe
hard some of the time for at least 60 minutes per day on 5 or more
of the 7 days preceding the survey
(2) Attended physical education classes 5 days in an average week
when they were in school
Youth Behavioral Risk Survey, 2005
Walk - 3
• Over half (54%) of high school students (72% of 9 grade
students but only 39% of 12 grade students) attended
PE in 2005.
• In 2005, 45% of 9 graders but only 22% of 12 graders
attended daily PE.
• Among the 54% of students who attended PE, 84%
actually exercised or played sports for 20 minutes or
longer during an average class.
• High school students attending PE classes daily
decreased from 42% in 1991 to 25% in 1995, (stable
since then).
Walk - 4
• Physical education “time” does
not equal moderate to vigorous
physical activity
– The “HEALTHY” experience
• Mandating the time “by law”
does not result in change
– The California experience
Walk - 5
• Physical activity
– Assessing fitness
– Differing measures (by country, state)
• Analysis of data from around the world, including
the US.
– Approximate rate of decline in physical fitness is
about 0.5% per year since ~1980.
Pediatric Fitness: Secular Trends and Geographic Variability;
Editor(s): Tomlinson, G.R. Olds, T.S. 2007 Karger AG, Basel.
Walk - 6
• Parents estimate that their children get 11.5 hours of
physical activity per week.
• Children and youth average 6.5 hours per week (most of
which is not moderate to vigorous physical activity).
Walk- 7
• The American Heart Association recommends that
children and adolescents participate in at least 60
minutes of moderate to vigorous physical activity every
day.
• The Centers for Disease Control and Prevention
recommend that children and youth accumulate at least
60 minutes daily of moderate to vigorous physical
activity in a variety of enjoyable individual and group
activities.
• Pediatrics 117, 1834-1842, 2006
MVPA
Moderate activity+ 3.0 to 6.0 METs*
• (3.5 to 7 kcal/min)
Walking at a moderate or brisk pace
of 3 to 4.5 mph on a level surface
inside or outside, such as
• Walking to class, work, or the
store;
• Walking for pleasure;
• Walking the dog; or
• Walking as a break from work.
• Walking downstairs or down a hill
• Racewalking—less than 5 mph
• Using crutches
• Hiking
• Roller skating or in-line skating at
a leisurely pace
Vigorous activity+ > 6.0 METs*
• (more than 7 kcal/min)
• Racewalking and aerobic
walking—5 mph or faster
• Jogging or running
• Wheeling your wheelchair
• Walking and climbing briskly up a
hill
• Backpacking
• Mountain climbing, rock climbing,
rapelling
• Roller skating or in-line skating at
a brisk pace
http://www.cdc.gov/nccdphp/dnpa/physical/terms/index.htm
Walk - 8
• Simple Suggestions
– Walk zones (1 block, ¼ mile)
• Resources
– Google (anything)
– http://www.kidshealth.org
– http://www.mayoclinic.com/health/fitness/
– http://bam.gov (CDC)
– http://www.verbnow.com
Water/low fat milk are the only
beverages at home and school
Beverages - 1
A Math Lesson
• 3500 calories = 1 pound
• An imbalance of 100 calories per day = 36,500
calories in 1 year
• 100 calories = ~8oz of most sugared beverages
• 36,500 calories = 10.4 lbs
• So forget the math and just remember that an extra
100 calories per day caloric excess each day for a
year is 10 lbs (i.e., small changes can make a
difference)
Beverages - 2
Average 12-19 yrs of age drinks
 Boys
28 oz of soda / day
5% > 60 oz / day
 Girls
20 oz / day
5% > 36 oz / day
Beverages - 3




28 oz
3500 cal
325 cal/day
325 cal/day
= 325 cal
= 1 lb
= 119,233 cal/yr
~ 32.5 lbs/yr
Beverages - 4
The “Big Gulp” and a grab bag
of chips (99¢ all summer)
62 oz
= 720 cal
Chips
= 280 cal
1000 cal/day = 2 lbs/wk
“School’s out” = 20 lbs/10
weeks
Beverages - 5
“Texas Soda Wars”
Susan Combs
Beverages - 6
Benefit to schools
– $54 million (~$6/case)
– Sports equipment
– Scholarship
– Special programs
School budget from State = $14.4 bil (2002)
Total spending on education was 40.7 bil
Beverages - 7
 55 sodas per child per year at school
 55 x 240 calories = 13,200
 13, 200 / 3,500 = 3.77 pounds
 The average weight gain for:
– A 7 year old girl is ~4 lbs/year
– A 12 year old girl is ~10 lbs/year
– A 16 year old girl is ~6 lbs/yr
Beverages - 8
• Benefit to Beverage company
– 162 million (~$18/case)
– “Branding for life”
– “Captive audience”
– Positive public relations
– Advertising at a profit for
180 days/yr
Beverages - 9
It’s the economy, stupid!
Profit
$6.24 per case for soda
$1.80 per case for milk/water
Beverages - 10
•
•
•
•
•
•
Girls ages 9-10 at start
Followed for 10 years
(NHLBI Growth and Health Study)
2,371 girls
3 day food diaries
Anthropomorphic measures
http://www.nhlbi.nih.gov/resources/deca/descriptions/nghs.htm
Beverages - 11
Age (years)
9.5
12.5
15.5
18.6
Regular soda (gms)
Diet soda (gms)
Milk (gms)
Fruit juice (gms)
36
22
352
110
217
50
320
104
274
71
290
125
377
82
242
129
Fruit drinks (gms)
78
95
80
87
377 gms = ~12 ounces of soda = 140 calories = 14 lbs per year
Guess which
color is the
“healthy stuff”?
Limit Use of Fast Foods
(1X/week)
Fast Foods - 1
Pop Quiz
A Big Mac, Supersized Fries and a 16 oz shake contain
enough calories to:
1. Be an excellent lunch choice for you
2. Be the total daily nutrient intake of a health adult female
3. Be the total daily nutrient intake for a marathoner
4. Be the ideal lunch for a hungry 10 year old
Fast Foods - 2
Pop Quiz
Answer: This is the entire
daily caloric need for
the typical adult female
or 80% of the needs for
the adult male.
Answer: To burn off this
many calories, one
needs to walk ~4 hours
http://www.primusweb.com/fitnesspartner/
jumpsite/calculat.htm
Fast Foods - 3
Meals eaten “out” (1996)
% of weekly food budget
% children eating out/day
Children’s fast food $
30%
45%
40%
21 bil
Fast Foods - 4
Portion size (1977-1996)
• Desserts
• Burgers
• Mexican food
JAMA 2003; 289:450-453
Calories
+55
+96
+133
Fast Foods - 5
• High energy
(calorically dense)
• High total and
saturated fat
• High cholesterol
• High sodium
J Am Diet Assoc 2003; 103: 1332-1338
•
•
•
•
Low Vitamin A & C
Low folic acid
Low calcium
Low fiber
Fast Foods - 6
National survey
4-19 year olds
Eating Out
Eating at home
Calories
2236
2049
Total fat (gm)
84
75
Total CHO (gm)
303
277
Fiber (gm)
13.2
14.3
Milk (gm)
236
302
Fruits/Vegs (gm)
103
148
Pediatrics 2004; 113:112-118
Fast Foods - 7
Supersizing
Calories
Fat (gm)
Hamburger
280
10
Quarter pounder & cheese
540
29
Small fries
230
10
Supersize fries
610
29
Soft drink (12 oz)
150
0
Soft drink (supersize)
410
0
660 calories vs 1660 calories (250% increase)
Fast Foods - 8
• Longitudinal study, girls, age 8 &12 at start
– Fast food ≥ 2 / week vs ≤1 / week
– More rapid increase in BMI over time
• Cross sectional, both sexes, ages 4 -16
– Overweight – more servings of food and
beverages away for home
– this correlated with the % body fat
Fast Foods - 9
Tips for parents
• The best “combo” is fast food with activity (e.g., post
hike)
• Avoid supersizes, doubles, etc (>500 calories beware)
• Brainstorm about easy food to prepare at home (and use
the internet)
• Moderation in all things/appropriate portion sizes
• Start early, with yourself (parents are role models)
• Offer choices, but limit them (milk or water)
• Toys come from the toy store, not the restaurant
• Use the websites of fast food restaurants – find those
things that < 500 calories
Snack foods – whole fruit and
vegetables
Fruit and Vegetables - 1
• < 15% of elementary students eat the recommended
5 or more servings of fruits and vegetables every
day.
• Average fruit and vegetable intake among 6-11 year
olds is only 3.5 servings a day.
• >50% of all elementary students eat no fruit on any
given day and 3/ 10 students eat <1 serving of
vegetables a day.
• 1/4 of all vegetables eaten by elementary students
are French fries, a high-fat, low nutrient vegetable
option.
Fruits and Vegetables - 2
• 2 year olds
116
• 5 year olds
107
• Primary care provider office (well-child
check-ups) , white middle class families
• 7 day diet diaries (careful instructions)
• Calculations based on USDA guidelines
Dennison, et al. J Am Coll Nutr 17:371-378 (1998)
Fruit and Vegetables - 3
Most children
eat less than
1 serving of
fruits, fruit
juices or
vegetables
per day and
this does not
vary much by
age
Fruit and Vegetable - 4
Energy density (Calories per gram)
• High-energy-dense foods: 4-9 calories per gram
(e.g., cookies, crackers, butter, bacon)
• Medium-energy-dense foods: 1.5-4 calories per
gram (e.g., bagels, dried fruits, hummus, partskim mozzarella)
• Low-energy-dense foods: 0.0-1.5 calories per
gram (e.g., most fresh fruits and vegetables,
fat-free yogurt, broth-based soups)
Fruit and Vegetable - 5
• Feeling full is more likely to make a person
stop eating than the total calories consumed.
– 20 participants ate as much as they wanted from food
offered to them over 5 days.
– The diet alternated from low-energy-dense to highenergy-dense foods.
– The participants felt full on the low-energy-density diet
after eating just over half the calories (1570 kcal) they
consumed before feeling full on the high-energy-density
diet (3000 kcal).
• * Duncan KH, Bacon JA, Weinsier RL. The effects of high and low
energy density diets on satiety, energy intake, and eating time of
obese and nonobese subjects. Am J Clin Nutr 1983;37:763-7.
Fruits and Vegetables - 6
• Short-term studies: Low-energy-dense foods promoted
feeling full, reduced hunger, and provided fewer calories.
• Long-term studies: Low-energy-dense foods promoted
moderate weight loss.
• Studies lasting longer than 6 months: Weight loss was
3X greater for people who ate foods of low energy
density than for those who simply ate low-fat foods.
Yao M, Roberts SB. Dietary energy density and weight regulation. Nutr Rev
2001;59:247-58.
Fruits and Vegetables - 7
• Whole fruit is more filling (satiating).
• Whole fruit contains fiber, and juice is fiber-free.
*Haber GB, Heaton KW, Murphy D, Burroughs LF. Depletion and disruption of
dietary fibre. Effects on satiety, plasma-glucose, and serum insulin. Lancet
1977;2:679-88.
*Bolton RP, Heaton KW, Burroughs LF. The role of dietary fiber in satiety,
glucose, and insulin: studies with fruit and fruit juice. Am J Clin Nutr
1981;34:211-17.
Review* of Dietary Intervention
Studies
Many studies have found that significant weight
loss can occur when advice to increase the
intake of fruits and vegetables is coupled with
advice to reduce energy intake.
*Rolls BJ, Ello-Martin JA, Tohill BC. What can intervention studies tell
us about the relationship between fruit and vegetable consumption
and weight management? Nutr Reviews 2004;62:1-17.
I DARE YOU
(for the child over 2)
1.
2.
3.
4.
5.
Limit screen time to <2 hrs/day
At least 1 hr of MVPA per day
Water/low fat milk are beverages of choice
Fast food is a 1 time per week treat
Fruit and vegetables are the only snacks
Beginning the Discussion
• Aspirational (Teens)
– What do you want to be doing 20 years from
now?
• Generational (Parents/grandparents)
– Breaking the chain
• Emotional (Parents of younger children)
– Making memories for your children
Your roles
• Be a role model (your behaviors are noticed)
• Pay attention to activity levels, sedentary
behaviors and eating habits in children (and
advocate for healthy alternatives)
• Provide information on healthy eating/
physical activity to children and parents when
the opportunity presents itself
• Promote sustainable behaviors in your
community
Think about ……
For thousands of years,
Physical activity was required for survival
Entertainment involved interaction with
other humans
Starvation was the enemy most feared.
Think About This
For thousands of years,
 Physical activity was required for survival.
 Entertainment involved interaction with other humans.
 Starvation was the enemy most feared .
In this modern age,
 Physical activity has been replaced by technology.
 Most entertainment involves interaction with a television
or a computer.
 Abundance is now the plague that will rob children of
their eyes and limbs.
If you are concerned about your child’s
weight (or your own weight), then here are 5
things that you can begin to change.
1.
2.
3.
4.
5.
Turn off the television (& computers and play stations)
No more than 2 hours/day for kids > 2 years old
Children walk (run, bike, hike, swim)
At least 1 hour of vigorous physical activity
No sugary beverages (sodas, sports drinks, fruit juices)
Water/low fat milk are the only beverages at home
Fast food is a treat
1 time per week (beware of any “meal” >500 calories)
Healthy snacks
Fruits and vegetables (beware of everything else)
Here’s How
•
•
•
•
Why do you want to change?
What do you want to change?
What are you doing now?
How are you going to get your family
involved?
• Who is going to support you (and keep
you honest)?