88th annual postgraduate convention | llu homecoming · divided by the square of height in meters....

88TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING

ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY

Marti Baum, MD, FAAP

Pediatrician, School of Medicine, Loma Linda University.

Director – Operation Fit Camp

Department of Pediatrics Director of OK KIDs community program

Medical Directory Community Engagement Social Action Community Health System Federal Qualified Health Clinic

Medical Directory for Community Health Development, Institute for Community Partnerships Loma Linda University

Disclosure -None



Childhood Obesity 2020

1. Understand the widespread effect of childhood obesity on health and social and emotional domains

2. Understand the complexity of factors contributing to obesity in children and review highlighted issues

3. Review promising and recent interventions for obesity in children



CHILDHOOD OBESITY A Growing Complex Problem In

America



Childhood Obesity

•Definitions•Population Concerns•Social Determinants of Health – Place Matters

•Behavioral Health Implications•Education System Impact•Health System Considerations•Built Environment •Food•Interventions and Policy



DefinitionsOVERWEIGHTChildren with a BMI at or above the 85th percentile and less than the 95th percentile

OBESITYChildren with a BMI at or above the 95th percentile

BMIBody Mass Index (BMI) is a person’s weight in kilograms divided by the square of height in meters. BMI for a child is defined in percentiles



According to the WHO…..Prevalence

•2016, more than 1.9 billion adults aged 18 years and older were overweight.

• 39% of men and 40% of women were overweight

•2016, about 13% of the world’s adult population were obese• 11% of men and 15% of women were obese, totaling 650 million • worldwide prevalence of obesity nearly tripled between 1975 and 2016.

• 2018, 40 million children under the age of 5 years were overweight or obese .

• Once considered a high-income country problem, overweight and obesity are now on the rise in low- and middle-income countries, particularly in urban settings.

• Africa, the number of overweight children under 5 has increased by nearly 50%since 2000.

• Almost 50% of the children under 5 who were overweight or obese lived in Asia.

•2016, 340 million children and adolescents aged 5-19 were overweight or obese.



Prevalence of overweight and obesity among children and adolescents aged 5-19 years

19751% of children and adolescents were obese.4% of children/adolescents were overweight and obese18% in 2016

2016 18% of girls and 19% of boys were overweight.6% of girls and 8% of boys were obese.

Overweight and obesity are linked to more deaths worldwide than underweight.



Obesity WIC 2-4 year olds 2010 to 2014 Changes



Place Matters



Place Matters

A person’s ZIP code is a much more powerful predictor of health than their genetic code, especially in those communities and populations experiencing the greatest health disparities.



Place Matters



Behavioral Health

Services



AdverseChildhood EventsBehavioral Health Services

ACE in Early Childhood and Kindergarten Outcome

Urban cohort of 1007 birthsPrimary care giver-reported ACE

exposuresTeacher reported outcomes in

Kindergarten

55% - 1 ACE12% - >3 ACE

Below-average language/literacy skills math skillsattention skillssocial solving problemshigher aggression

PEDIATRICS, Vol. 137 No. 2 February 2016



Adverse Childhood Events

Distribution of ACEsAcademic Pediatrics, Volume 15, Issue 5, 2015, 510-517

Adverse Childhood Experiences and Mental Health, Chronic Medical Conditions and Development in Young Children,

Kerker, Zhang, Nadeem, Stein, Hurtburst, Heneghan, Landsverk, McCue Horwitz.



BuiltEnvironment



American Academy of PediatricsMEDIA Policy

< 18 months Only video chat with parental supervision18-24 months No solo viewing, high quality

programming with parent co-viewing2-5 years 1 hour per day high-quality programming,

co-viewing and explanations



Media Policy from AAPEducational System

•Heavy media use in preschool associated with increased BMI

•BMI increased for every hour per week of media consumed

•Food advertising•Watching TV while eating diminishes the satiety feedback

•Night-time sleep shorter with evening screen media exposure*

•Well designed TV programming such as Sesame Street and PBS show efficacy 3-5 y/o

•Most apps not designed for dual viewing, parents and preschoolers.



Built Environment - Root Cause Analysis

•Childhood obesity has reached epidemic proportions.•Two main components of childhood obesity

•Physical Inactivity •Improper Nutrition

•Neighborhood attributes and challenges•Physical Attributes – Decreased association with obesity

• Walkability/bikeable environment • Mixed land use• Accessible destinations • Transit increase resident physical activity • Neighborhood supermarkets/farmer’s markets

•Physical Challenges – Increase association with obesity• Access to high-caloric foods• Convenience storesMt Sinai J Med 78:49-57, 2011, Authors Tamanna Rahman, Rachel A. Cusing, Richard J. Jackson



HealthServices



Parent Perception

•Children whose parents perceived their weight as being “overweight,” as opposed to “about the right weight,” gained more weight (increase in BMI z score) from baseline to follow-up.

•The association between perceiving one’s child as being overweight and future weight gain.



ObesityHealth ServicesMillennium Cohort Study

• BMI trajectory• Psychosocial well-being

Ages 3, 5, 7,11 years

N=16,936 participants

BMI• 0.6% decreasing • 83.8% stable normal• 13.1% mod. increasing • 2.5% high rising

Resource: PEDIATRICS, Dec 2016, p 84

Early Life Factors • Smoking in pregnancy• Skipping breakfast• Bedtime routines

Moderate and high rising BMI• Emotional symptoms, less “happy”• Peer problems• Body satisfactions• Self-esteem

Hi rising BMI • Tried alcohol• Tried cigarettes.



Obesity as a Disease



Focused Review of Systems/Co-morbidity



Diagnostic Work-up: Labs and Studies



General Intake Guidelines (Normal Weight): 5-18 years of age



Management of the Infant with Obesity: 0-24 Months



Food



FoodAs

Health



Rising Poverty Rates for ChildrenFood

•Unprecedented Nutritional Crisis•Obesity Crisis•1 in 5 children live in households with food scarcity

•Special Suppl. Nutritional Program for Women Infant and Children (WIC)

•Suppl. Nutritional Assistance Program (SNAP)

•50% of calories consumed at school. Feeding stations-vacations

•20 Well Child Visits 0-5 yr•31 Well Child Visits 0-21 yr

•Every $1.00 spent on WIC•Saves $3.50 in reduced payments of Medicaid due to health related “down stream” diseases.

Resource: AAP Institute for Healthy Childhood Weight developed Healthy Active Living for Families



EducationSystem



Students Who Are Overweight or Obese, by Grade Level: 2018(Grade Level: All)

Definition: Percentage of public school students in grades 5, 7, and 9 with body composition falling above the "Healthy Fitness Zone" of the FitnessGram assessment, by grade level (e.g., in 2018, 40.5% of California 5th graders were overweight or obese).

Data Source:As cited on kidsdata.org,California Dept. of Education, Physical Fitness Testing Research Files (Dec. 2018).

https://www.kidsdata.org/topic/725/student-weight-current/Bar



Physical Education and Activity Opportunities at School



Students Meeting All Fitness Standards, by Grade Level: 2011 to 2018(Grade Level: Grade 5)

Definition: Percentage of public school students in grades 5, 7, and 9 meeting six of six fitness standards (e.g., in 2018, 24.3% of California 5th graders met all fitness standards).

Data Source:As cited on kidsdata.org,California Dept. of Education, Physical Fitness Testing Research Files (Dec. 2018).

https://www.kidsdata.org/topic/310/fitnessstandards/trend



Childhood ObesityEducation & Regular Exercise 61% with any college50% with high school diploma37% with less than high school diploma



Obesity in ChildhoodFood

Agency for Healthcare and Quality - AHRQ1 in 3 children are overweight or obese•34,500 articles reviewed•131 articles used for evaluation•High income country•Study conducted by randomized trial

•Children: 2-18 years of age•Followed: 6-12 months for outcome



Obesity in ChildhoodFood

•Agency for Healthcare and Quality – AHRQ

Wang, Wu, Wilson, et al,

www.effectivehealthcar.AHRQ.gov.child-obesity-prevention.CFM

Recommendations•What works, not much in clinics!•School-Based Programs involving dietary or physical activity interventions are effective in preventing childhood obesity

•Combining a home or community component with a school based program also works

•Magnitude of effects appear to be modest even with heterogeneity due to study interventions, outcomes and duration.



Policy and Law

Policy & Law



WIC Participants 2-4 y/o Obesity %

2016

2010



Policy Options: Improve Children's Physical activity

1. Ensuring adequate funding, support, and compliance monitoring systems so that all schools meet or exceed state physical education requirements

2. Continuing to promote walk to school and Safe Routes to School programs, to increase the number of children walking or biking to school

3. Encourage schools to make recreational facilities available for use outside of school hours, especially in neighborhoods that lack such facilities.

4. Strengthening and ensuring implementation of policies to promote physical activity in after-school and early childhood settings

Promoting collaboration across sectors to address structural barriers that limit opportunities for physical activity especially in low-income areas and communities of color



CDC RecommendationsPolicy and Advocacy at all levels•Structures to support policies and interventions

•local influence and a voice for health•“Health-in-all” for standards and guidelines

•Population-wide policies and initiatives•Marketing of unhealthy foods and beverages to children•Nutritional labelling•Restaurant initiatives•Fruit and vegetable initiatives•Physical activity policies

•Community-based interventions•School connections with community based support



Social SupportServices



Obesity and Bullying



Weight-related bullying can occur as early as 3 years of age.



Elementary and Middle School Years

Less peer acceptanceFewer friend nominationsPerceptions of being less athletic and unattractiveStereotypes of being lazy, unfriendly, dishonestNo differences according to gender, race or grade

63% higher rates of being bullied for a child with obesity than healthy weight peer.



High School Years

40.8% of teens state they are teased because of their weight.



Obese children who have been bullied are at increased risk for:

Avoid exercising-such as skipping PE classesLess motivation to exerciseCope with bullying by avoiding exercisePoorer friendship qualityIncreased isolationHigher depression rates



Who is teasing our children?

Peers 90%Friends 70%PE Teachers or

Coaches 42%Parents 37%



Types of bullyingVerbal bullying includes: TeasingName-callingInappropriate sexual comments TauntingThreatening to cause harm

Social bullying, involves hurting someone’s reputation/relationships. Leaving someone out on purposeTelling other children not to be friends with someone Spreading rumors about someoneEmbarrassing someone in public

Physical bullying involves hurting a person’s body/possessions.Kicking/pinching/hittingSpittingTripping/pushingTaking or breaking someone’s things Making mean or rude hand gestures

Cyber bullying http://www.onlineschools.org/student-bullying-guide



ACADEMIC CONSEQUENCES

Academic Consequences

Students who are bullied for their weight state report their grades are harmed and admit to wanting to avoid school

Weight-based teasing mediates relationship between BMI and poor school performance.



Tips for Parent inTalking …..with their children about weight

Start an open conversation with your childIdentify mutual ways to resolve the challenge areasListen to understand not just respond!Help repair self esteem



Reference for Educational M

aterials



•Improving Community Health, One Neighborhood at a Time, 2018, Research to Action, Nutrition Policy Institute •Neighborhood Characteristics and Children’s Physical Activity, 2014, Child Trends, Cooper, M., & Murphey, D. •Physical Activity Guidelines for Americans (2nd ed.), 2018, U.S. Dept. of Health and Human Services •Physical Activity Opportunities in Afterschool Programs, 2015, Health Promotion Practice, Weaver, R. G., et al. •Physical Activity Resource Guide: Implementing Physical Activity Programming for SNAP-Eligible Populations (2nd ed.), 2018, California Dept. of Public Health •Physical Education Policy Compliance and Latino Children’s Fitness: Does the Association Vary by School Neighborhood Socioeconomic Advantage?, 2017, PLoS ONE, Sanchez-Vaznaugh, E. V., et al. •Policies for Promotion of Physical Activity and Prevention of Obesity in Adolescence, 2016, Journal of Exercise Science and Fitness, Pate, R. R., et al. •Sedentary Behaviors and Youth: Current Trends and the Impact on Health, 2014, Active Living Research, Lou, D. •The Influence of Physical Activity, Sedentary Behavior on Health-Related Quality of Life Among the General Population of Children and Adolescents: A Systematic Review, 2017, PLoS ONE, Wu, X. Y., et al. •The Whole School, Whole Community, Whole Child Model, 2015, Journal of School Health, Hunt, H. (Ed.) •United States Report Card on Physical Activity for Children and Youth, 2016, National Physical Activity Plan Alliance•Using Cost-Effectiveness Analysis to Prioritize Policy and Programmatic Approaches to Physical Activity Promotion and Obesity Prevention in Childhood, 2017, Preventive Medicine, Cradock, A. L., et al.

References for Physical Activity

https://us15.campaign-archive.com/%3Fu=035add68caaa2141721d3d303&id=ab4e1d7f51

https://www.childtrends.org/publications/neighborhood-characteristics-and-childrens-physical-activity-2

https://health.gov/paguidelines/second-edition

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4428667/

https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/NEOPB/CDPH%2520Document%2520Library/Final%2520PARG%25206.2.18.pdf

http://journals.plos.org/plosone/article%3Fid=10.1371/journal.pone.0178980

https://www.sciencedirect.com/science/article/pii/S1728869X1630154X

https://activelivingresearch.org/sedentaryreview

http://journals.plos.org/plosone/article%3Fid=10.1371/journal.pone.0187668

https://onlinelibrary.wiley.com/toc/17461561/85/11

http://www.physicalactivityplan.org/projects/reportcard.html

https://activelivingresearch.org/using-cost-effectiveness-analysis-prioritize-policy-and-programmatic-approaches-physical-activity



•Active Education: Growing Evidence on Physical Activity and Academic Performance, 2015, Active Living Research, Castelli, D. M., et al. •Adolescent Physical Activity: Role of School Support, Role Models, and Social Participation in Racial and Income Disparities, 2015, Environment and Behavior, Babey, S. H., et al. •Early Care and Education Policies and Programs to Support Healthy Eating and Physical Activity: Best Practices and Changes Over Time, 2017, Healthy Eating Research, Fox, T., et al. •Framework for Action: Addressing Nutrition and Physical Activity through ESSA Implementation, Alliance for a Healthier Generation & Healthy Schools Campaign Pediatric Obesity Algorithm: A Practical Approach to Obesity Diagnosis and ManagementSuzanne E. Cuda1,*and Marisa Censani

References for Physical Activity / O

besity Managm

ent

http://activelivingresearch.org/ActiveEducationBrief

http://journals.sagepub.com/doi/abs/10.1177/0013916515609086

http://healthyeatingresearch.org/research/early-care-and-education-research-review-2010-2016

https://healthyschoolscampaign.org/wp-content/uploads/2017/06/Framework-for-Action-Nutrition-and-Physical-Activity.pdf

https://www.ncbi.nlm.nih.gov/pubmed/%3Fterm=Cuda%2520SE%255bAuthor%255d&cauthor=true&cauthor_uid=30729102

https://www.ncbi.nlm.nih.gov/pubmed/%3Fterm=Censani%2520M%255bAuthor%255d&cauthor=true&cauthor_uid=30729102



Registered Dietitian, Angie Hasemann, RD, CSP, https://www.cdc.gov/healthyschools/obesity/facts.htmWebinarhttp://www.uconnruddcenter.org

https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/provisional-section-on-obesity/Documents/Webinar_Importance_Addressing_Weight_based_Bullying.pdf.https://letsmove.obamawhitehouse.archives.gov/health-problems-and-childhood-obesity

NAFAA KIDS PROJECT WWW.NAAFA.ORG/KIDSNEW.HTML

BULLIES CAN BE TRANSFORMED WWW.BULLIESCANBETRANSFORMED.COM

STOP BULLYING NOW! WWW.STOPBULLYINGNOW.HRSA.GOV

A CALL TO STOP BULLYING HTTP://WWW.QUALITYANSWERINGSERVICE.COM/RESOURCES/CALL-STOP-BULLYING

GIRLS HEALTH WWW.GIRLSHEALTH.GOV/PARENTS/BULLYING.CFM

AT BULLYING WWW.BEATBULLYING.ORG

References for Bullying and O

besity

https://www.cdc.gov/healthyschools/obesity/facts.htm

http://www.uconnruddcenter.org/

https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/provisional-section-on-obesity/Documents/Webinar_Importance_Addressing_Weight_based_Bullying.pdf

https://letsmove.obamawhitehouse.archives.gov/health-problems-and-childhood-obesity

http://www.naafa.org/KIDSNEW.HTML

http://www.bulliescanbetransformed.com/



HEALTH



Bullying and SuicideSocial Support Services

Suicide is 2nd leading cause of death, 15-19 yr•1 Victim or perpetrator of bullying•2. Pathological internet use – greater than 5 hr/d on games or internet associated with higher levels of depression.•3. Cyber bullying has similar increases in suicide attempts with face-to-face bullying, both victim and bully.Depression is s significant suicide risk factory, however, risk of NOT prescribing an antidepressant medication is significantly higher than risk of prescribing.



Pediatric Updates March 5, 2017

Marti Baum, MD, FAAP



Operation Fit



PROGRAM EXPECTATIONS

- PROGRAM WILL REQUIRE FOR PATIENT AND PATIENT’S PARENTS TO BE HIGHLY MOTIVATED TO CHANGE- ATTENDANCE TO ALL SESSIONS



PROGRAM’S UNIQUENESS

- FOCUS ON BEHAVIORAL EFFECTS OF WEIGHT-BASED BULLYING - INTEGRATION WITH PSYCHOLOGY



LLU’S WEIGHT PROGRAM WILL INCLUDE:

- 15 SESSION PROGRAM- MULTIDISCIPLINARY APPROACH- WEEKLY GROUP VISITS WILL INCLUDE MEETING WITH PHYSICIAN, DIETICIAN AND PSYCHOLOGIST - EDUCATION TO PROMOTE HEALTHY LIFESTYLES CHANGES



MANY FACTORS CONTRIBUTE TO CHILDHOOD OBESITY, INCLUDING:

- GENETICS- METABOLISM—HOW YOUR BODY CHANGES FOOD AND OXYGEN INTO ENERGY IT CAN USE- EATING AND PHYSICAL ACTIVITY BEHAVIORS- ENVIRONMENTAL FACTORS- SOCIAL AND INDIVIDUAL PSYCHOLOGY



LOMA LINDA’S PEDIATRIC WEIGHT PROGRAM: A SOLUTION TO OBESITY AND WEIGHT-BASED BULLYING



OBESITY AND BULLYING



LONG TERM EFFECTS OF BULLYING

-REDUCED OCCUPATIONAL OPPORTUNITIES

- DIFFICULTY TRUSTING PEOPLE

-INTERPERSONAL DIFFICULTIES, INCLUDING FEAR AND AVOIDANCE OF NEW SOCIAL SITUATIONS

-INCREASED INCIDENCE OF CONTINUED BULLYING AND VICTIMIZATION



Place Matters



ABOUT 1/5OF

TEACHERS REPORTED CONCERN

ABOUT BULLYING RELATED

TO WEIGHT



Place Matters



OBESE CHILDREN ARE AT INCREASED RISK FOR:

- HEART DISEASE- HYPERTENSION - TYPE 2 DIABETES- ASTHMA- SLEEP APNEA- SOCIAL DISCRIMINATION



ObesityHealth Services

• Childhood obesity in San Bernardino County (SBC) is close to double the national rate

• A policy brief on childhood obesity indicated that childhood obesity was more of a problem in California and specifically in SBC (Imbir et al, 2010)



Academic FailureEducation System



SOCIAL