Clinical & Community Collaboration to Combat Obesity

Cindy Wolff, PhD, MPA, RD Nutrition and Food Sciences, CSUCOPT for Fit KidsDirector

Clinical & Community Collaboration to Combat Obesity

• Cindy Wolff, PhD, MPA, RD • Carol Lams MA, RD Director Outreach Coordinator

• Faye Johnson, EdD, RD • Michele Buran Awareness Campaign Director Exercise Physiologist

• Kristin Gruneisen, MS, RD • Regina Munster, MS Clinical Dietitian Nutritionist

The obesity problem in the US is gaining attention

Obesity is Changing Human Shape1980: Male - 73 kg (162#); Female - 62 kg (136#) 2000: Male - 82 kg (180#); Female - 69 kg (152#)

>33% of US Adults Are Obese

In 1983, only 15% were obese.

80%?! Are Now Overweight

We are not only fat, but we are getting fatter fast:

1983: 58% were overweight 1990: 64% 1995: 71% 2002: 80%

Meet

Generation

Xcess

School-Age Children

In 2000, 26% were either:

–Obese (11%) or

–Overweight (15%)

When today’s 50 year olds were 10, only 4% of kids were overweight vs 26% today.

Rate of Overweight (% Obesity) in Low-Income Butte County Children

Ethnic Group

24-35 mo. 36-59 mo. 5-9 yr.

White 6.2 8.3 11.4

Hispanic 10.0 13.4 19.8

Asian 11.3 12.8 15.2

*PedNSS data for years 1995, 1996, 1998, & 1999 were used to calculate mean rates.

1012141618202224

1995 1996 1997 1998 1999

% >

95th

White Hipanic Asian

Butte County PedNSS DataAges 5-9 yrs.

CA Fitnessgram Results, 2001

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Overwt Unfit

3rd ADCA26th AD

Butte County WIC Study

N = 131 mothers and preschoolers45% of moms had some college (or

more)Half of mothers of overweight

children indicated that their children were normal weight

Overweight among preschoolers was associated with more frequent fast food

BMI category - Mothers

underweight6%

normal 34%

overweight27%

obese33%

underweight

normal

overweight

obese

BMI-for-age percentile - Boys

normal or underweight

69%

at risk of overweight

11%

overweight20%

normal or underweight

at risk of overweight

overweight

BMI-for-age percentile - Girls

normal or underweight

62%

at risk of overweight

23%

overweight15%

normal or underweight

at risk of overweight

overweight

Gridley Schools Data (n=554)

Mean age = 9 yrs

> 85% BMI-for-age = 52%

> 95% BMI-for-age = 30%

Double the national average

                                                                                              

                                                                      

“Acanthosis Nigricans” signals high insulin levels & can help identify persons who run the risk of developing diabetes

Acanthosis Nigricans

12% are positive for acanthosis

1 out of 8 kids

22% if >85% BMI-for-age

36% if > 95% BMI-for-age

>90% of these kids are Hispanic

MNT for Aganthosis Nigricans

Dietitians can conduct 2 evaluations and 4 intervention sessions with the child and family under CPT code 701.2 “Acquired Acanthosis Nigricans”

0

5

10

15

20

25

30

35

BMI

1985 2000

Pima inMexicoPima inUS

Genetics vs. EnvironmentThe Pima Example

The 4th Law of Thermodynamicsor

Life Isn’t FairThe Theory

Dietary Intake -

Energy Expenditure =

Energy Stores Including Adipose Tissue

The Truth

(Dietary Intake x Genetic Modifier) -

(Energy Expenditure x Genetic Modifier) =

Energy Stores Including Adipose Tissue

FAST FOOD: An Attractive Nuisance

Americans spend more money on fast food than they do on:higher education, computers & software, or new cars

And more on fast food than on movies, books, magazines, newspapers, videos and recorded music - combined.

July 28, 2002 California’s Official Drive-Through Day!!!

Jack in the Box lobbied heavily for this state declaration.

Gov Davis agreed

With 24 hr service at drive-throughs, there’s no time that fast food is out of reach.

Healthy People 2010

The Leading Health Indicators are: 

1. Physical Activity 2. Overweight & Obesity 3. Tobacco Use 4. Substance Abuse 5. Responsible Sexual Behavior 6. Mental Health 7. Injury and Violence 8. Environmental Quality 9. Immunization 10. Access to Health Care  

Childhood ObesityThe ProblemChildhood ObesityThe ProblemConsidering childhood obesity is a new

conceptLittle to no mention in textbooksPhysicians don’t always address the issueWhy address the issue if there is no

effective treatment?

CA Obesity Prevention Initiative survey results:90% of medical directors indicated a

need for provider resources, e.g. a toolkit & training for obesity prevention & treatment

100% reported a need for patient resources for teens & children

- Jan. 2003

OPT for Fit Kids: A Community Network Approach to Child Obesity

• Cindy Wolff, PhD, MPA, RD • Carol Lams MA, RD Director Outreach Coordinator

• Faye Johnson, EdD, RD • Michele Buran Awareness Campaign Director Exercise Physiologist

• Kristin Gruneisen, MS, RD • Regina Munster, MS Clinical Dietitian Nutritionist

OPT Mission

To reduce the incidence of

pediatric overweight through:

– increased public awareness of

the severity of the problem, &

– by providing nutrition

education prevention and

treatment services.

OPT for Fit Kids Program Components

1. Medical Nutrition Therapy:

Nutrition assessment and

counseling services for

overweight children and

their families.

OPT for Fit Kids Program Components

2. A multi-media campaign to

increase awareness of the

prevalence and severity of

pediatric overweight and

lifestyle practices for its

prevention and treatment.

OPT for Fit Kids Program Components

  3.  Early childhood nutrition education for Head Start children, parents, and teachers.

Fitness is the FOCUS

Not Weight

OPT Clinical Services

Medical nutrition therapy:Group classes

(L.E.A.P.)Family

counselingThe focus is on

fitness and quality of life, not weight.

Description of OPT Participants (n=181)

Mean No. %

Age 10 yr

2-12 yr 132 73

13-17 yr 49 27

Height 4’10”

Weight 158#

BMI-for-age 31.3

% Body fat 42%

Note: A BMI-for-age of 20 = 85th %tile

Description of OPT Participants, cont. (n=181)

No. %

Insurance:

Medi-Cal 97 72

Healthy Families 14 8

Private 46 25

Uninsured 24 13

Ethnicity:

White 93 72

Hispanic 13 19

Other 12 9

Description of OPT Participants, cont.Biochemical Values Baseline S.D.

Total Cholesterol 180 mg/dL 37

HDL-Cholesterol 42 9

LDL-Cholesterol 114 32

Triglycerides 137 81

Total Chol/HDL ratio 4.4 1.1

Blood Lipids

60% have elevated cholesterol

42% low HDL

51% high LDL

33% high triglycerides

48% had a total cholesterol/HDL ratio 4.5

0

10

20

30

40

50

60

Chol LDL Chol/HDL

Hyperinsulinemia & BMI-for-age

66% had insulin values >12 uU/mL

Significant association between BMI-for-age and insulin values

0

5

10

15

20

25

30

35

40

27.3 38.3

<12uU/mL>12uU/mL

OPT for Fit Kids Outcomes MeasuresDietary changesActivity patternsFitness levelBiochemical valuesBMIQuality of lifeFamily communicationKnowledge & attitudes

Outcomes for OPT Weight Management Participants

82% had a decrease in BMI

Mean decrease was 1 BMI unit

2# weight loss with ½” gain in height

31.4

31.6

31.8

32

32.2

32.4

32.6

32.8

Pre BMIPost BM

Decrease in Body Fat

% body fat decreased from 42.0% to 40.0%

39

39.5

40

40.5

41

41.5

42

42% 40%

PREPOST

Parents reported significant improvements:My child eats more fruits & vegetables/dayOur family watches less television My child is more likely to eat until he/she

is “just satisfied” rather than very full or still hungry

Our family eats less fast foodI provide more physically active activities

for my childMy child drinks less sweet beverages

(juice, juice drinks, soda, Kool-Aid)

Children reported significant improvements:

I eat mainly low-fat (green light) foodsI exercise at least 60 minutes most days of

the weekI eat when I’m hungry and stop when I’m

satisfiedI accept my natural body-build

Needed changes:Health care providersHealth care providers need to assess

BMI-for-age for at risk children Talk to parents and child if > 85%

BMI-for-age Assess child for weight related co-

morbiditiesRefer for weight management services

if > 95% BMI-for-age

Steps to using BMI-for-age

Obtain accurate weight and height measurements

Calculate BMI or look up on chart

Plot measurements

Interpret plotted measurements

Case Study: “Sam”

Name: SamWeight: 43 lb 4 oz Height: 41.5 inches DOB (date of birth): 1/10/1998DOV (date of visit): 4/18/2003

Calculating BMI

Example: Weight = 43 pounds, 4 oz. Height = 41 1/2 inches

(convert fractions to decimal value)

BMI = [43.25 lb / 41.5 in / 41.5 in] x 703

= 17.7

Calculation: [weight (lb)/height (in)/height (in)] x 703

Sam’s BMI Plotted on Boy’s BMI-for-Age Chart

Interpretation:

• Sam’s BMI is slightly above the 90th %tileso it falls in the ‘risk for overweight’ range.

Boys: 2 to 20 years

BMI BMI

BMI BMI

Interpreting the BMI-for-age Chart

BMI-for-age indicates a child’s weight in relation to his/her height for a specific age and gender.

Need a series of BMI plots to

determine the growth trend.

If indices deviate from normal growth patterns, further assessment may be needed.

www.cdc.gov/growth/charts

Use this web site to download the new BMI-for-Age Growth Charts

Medical Evaluation of Childhood ObesityBMI 85-95%:

no risk factor

Fasting lipid profile

BMI 85-95%:

with risk factors

Fasting lipids, insulin, & glucose

HgA1CComp. chemistry panelThyroid function

BMI > 95% All of above  

Appropriate Weight Loss Rate?

One pound per month

Needed Changes - Schools should provide:Fitnessgram results to parents with

interpretive informationBMI-for-age & interpretive

informationA food environment supportive of

healthy life habitsThe state mandated minutes of P.E.Nutrition education as part of the

curriculum

Limit Liquid Sugar (Sodas)

As soda intake increases, weight increases.

Kids used to drink 2 glasses of milk for every soda. Now they drink 2 sodas for every glass of milk.

The chances of children becoming obese increases 1.6 x for EACH can or glass of sugary beverage/day. (Source: Experts Say Skip the Soda, Better Nutrition, May 2001)

Funding Sources for OPT

California Nutrition Network (USDA)

Butte County Commission on Children and Families (Prop 10)

OPT Community Partners

Butte County Head StartNutrition & Food Sciences, CSUC Butte County WICButte County Dept. of Public HealthUC Coop. ExtensionPediatric Health PractitionersValley Oaks Children ServicesAmerican Cancer Society

OPT for Fit Kids: Overweight Prevention & Treatment