childhood obesity: an american perspective eliana m. perrin, md, mph associate professor of...

Childhood Obesity: An American Perspective

Eliana M. Perrin, MD, MPHAssociate Professor of Pediatrics

Department of PediatricsUniversity of North Carolina at Chapel Hill

North Carolina, USA

Road Map for Today• The problem of pediatric

obesity in the US (some comparisons with France)

• How my research informs clinical practice and the reverse

• What I do as a pediatrician to help stop the epidemic

• Exchange ideas with each other and give each other tips

The prevalence of childhood obesity and its health consequences

•In the 1990s-reports that the health consequences of obesity appear in childhood as well as adulthood years. (Dietz WH, Pediatrics, 1998)

•Now, in 2012, 32% of US children and adolescents are overweight or obese (Ogden, et al, JAMA, 2012)

Obesity (not including overweight) prevalence in adults

Overweight and obesity prevalence in children

32%11-14%

After a short stay in a gallery in America, this is what happened to Michelangelo’s David…

Road Map for Today

Influences on Obesity:Demographics, cultural practices

Parental eating attitudes/feeding practices/societal weight attitudes

copyright Eliana Perrin, 2011

Television

Girls meeting physical activity recommendations in the USA

Boys meeting physical activity recommendations in the USA

Pass the popcorn: obesity in children’s movies

Watched top 4 grossing PG and G movies per year, 2005-2009- total 20

Coded for healthy and unhealthy food and exercise messages that match AAP statement on family obesity prevention

65% of segments showing food show food of too big portions 80% of segments showing food, show unhealthy snacks 55% of beverages shown are sugar-sweetened beverages 75% of movies show obesity related stigma

Why do we care?

What can we do?

Possible research and intervention focus areas

BUILT ENVIRONMENT CORPORATIONS/POLICY

COMMUNITY/CULTURAL

SCHOOLS/DAYCAREBIOLOGY/GENETICS

DOCTOR’S OFFICE

Primary care prevention in the doctor’s office involves at least a pediatric care provider and a

patient (parent/child or family)

My research attempts to understand both perspectives.

In the USA, this is now a national focus

Primary Care Providers’ Problem• “Healthy People 2010” charged primary care

providers with task of helping to stop the epidemic.

• Diagnosis of and screening for overweight

considered one of the 1st steps.

• Multiple studies show physicians under-diagnose overweight and obesity in both adults and children. (McArtor RE, et al, 1992; Denen ME, et al, 1993; Eck LH, et al 1994; Stafford RS, et al, 2000, Jain, et al, 2001; Jeffery, et al, 2005; Huang, et al, 2007; Benson, et al, Pediatrics, 2009)

Primary Care Providers’ Plight• Much expected to do with limited time:

BP, toilet training, temper tantrums, discipline, school, ADHD, vision and hearing, immunizations, anemia, lead screening, TB screening, cholesterol, sexuality and STD prevention, injury prevention, violence prevention, sleep positioning, and sleep disturbances, to say nothing of the physical exam, chronic problems, etc.

Belamarich PF, Gandica R, Stein RE, Racine AD. Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements. Pediatrics. Oct 2006;118(4):e964-978.

• Even obesity screening is complicated…

Screening for overweight always involves determining weight for height

Stop-light Color-Coded vs. standard BMI chart

“Visual impression”- how good is it?

“Visual impression”- how good is it?

BMI ~98th ObeseBMI ~93rd Overweight BMI ~12th Healthy

Obese

Age 6, >99th

BMI=23Age 12, >99th

BMI=29.8Age 2, 95th

BMI=19.2Age 4, 98th

BMI=18.5

So from what I have shown you, we know that pediatricians probably under-diagnose obesity because their visual impression is not accurate.

My early research confirmed this, and my later research has tried to overcome it. Both are informed by clinical perspective.

Allow me to share some study findings with you.

BMI vs. Height and Weight Study (Journal of Pediatrics, 2004)

CONCLUSIONS:

• BMI charting more effectively demonstrated that a hypothetical child was overweight and prompted greater concern about her than did height and weight charting together.

• Yet BMI charting, recommended by the CDC in 2000, was rarely being used.

IMPLICATIONS:

• Pediatricians had unique opportunities to prevent obesity, but not without detecting concerning weight trends.

• Further efforts were needed to help pediatricians adopt this useful tool.

Self-Efficacy Survey Study (Ambulatory Pediatrics, 2005)

CONCLUSIONS:• Pediatricians don’t feel effective in their treatment/prevention

of obesity but feel they could be potentially more effective.• Pediatricians identify environmental barriers as the most

frequently encountered but have low self-efficacy that’s most associated with practice-based barriers

• Desired many resources including better counseling tools and better ways of communicating weight status to parents.

IMPLICATIONS: • Interventions in office-based setting increase self-efficacy

increase counseling.• We need better ways to discuss weight status with parents and

motivate them toward healthy behavioral change

Barriers & facilitators of using BMI – pediatrician focus group study

(Flower, Perrin, et al, Ambulatory Pediatrics, 2007)

CONCLUSIONS:• There are many systems barriers to using BMI but it can be a

useful diagnostic and even counseling tool.

IMPLICATIONS: • Practice-level changes such as incorporating BMI into office

systems and electronic medical records may be needed to support pediatric primary care providers in using BMI routinely.

• More research on whether parents understand the concept of BMI or it serves as a communication tool

Pediatrician Weight Self-Perception Study (Obesity Research, 2005)

CONCLUSIONS:

• Nearly half of overweight pediatricians did not classify themselves as such and misperception of overweight was worse than in non-doctor US samples.

• Those identifying themselves as “thin” & those identifying themselves as “overweight” reported more difficulty counseling regardless of actual weight status.

IMPLICATIONS:

• Physicians’ weight self-perceptions may be one barrier to appropriate screening and counseling.

In my CLINCAL experience, this is what happens

If child is healthy weight, parent thinks child is SKINNY, and typically is trying to actively get the child to GAIN weight

If the child is overweight, parents think the child is at a healthy weight, and is certainly not changing their dietary or PA behaviors.

Both groups of parents need education about the child’s weight status and the appropriate recommendations.

The parent perspective

• Do parents know when their children are too heavy?

• Do parents understand the concept of BMI? What would help parents understand?

• What do parents find sensitive and motivating with respect to recommendations? What is their advice for doctors?

• What health effects are there of obesity at young ages and as predictors for the future that parents might find motivating?

The parent perspective- interviews

Be sensitive in our language

On what a doctor should say:

“Okay we're a little bit concerned, he looks like he's bigger than most kids his age or something of that sort, then it would've probably been okay, but I don't know, the ‘obese’ word, I, I don't like it.”

Get to know our patients and make tailored and realistic recommendations:

“You have to look at your socioeconomic stuff … You know you have to bring all of that in before you can sit down and make these high hat recommendations like you should take your child to the park more often. Well we don’t have a park in the inner city, not one that is not run by the gangs. Basically you are not allowed to play in the park in this neighborhood. So in order to make the recommendations that the doctors are wanting to make, they are going to need more personal information and they are going to need a way to get it without offending people. We live on $459 a month and my disability check. Forty fifty nine a month for three people. It is not feasible to recommend fresh vegetables when I can get ‘three-for-a-dollar’ cans, and the cans with the dents for a quarter. And that is the reality. You need to find out who you are talking to.”

Others say, “Tell us more about health than weight!”

“I would listen to advice on how, you know, I can make them healthier, not help them lose weight, 'cause I don't want to help (them lose weight).”

So we have spent a lot of time trying to providing families with evidence-based, brief, targeted counseling to

improve diet and physical activity

Culturally Appropriate Handouts

What to do as a pediatrician?

Why intervene so early in life?(preliminary work at our 4 GreenLight sites)

• How many 4 month olds in our clinics are getting juice / sugary drinks in the bottle??– 2 out of every 3 babies!

• What % of babies are introduced to solids before 4 months of age?– 1 out of every 5 babies!

• What % of 4 month old babies are fed “whenever they cry?”– 1 out of every 5 babies!

Key element is preventionFor prenatal and newborn visits:

• Encourage breastfeeding; teach parents infant hunger cues & to feed by cue not by the clock; discourage bottle propping

• For visits with babies and toddlers:

• Discussion as there is a transition to solids- time to focus on the whole family eating together & on healthy foods- fruits and vegetables, whole grains, lean meats, cooking styles, appropriate portion sizes

• Beverage counseling- milk as meal-time beverage and water for thirst quenching. Discourage sweet tea, soda, lemonade, JUICE

Encourage physical activityEncourage activity for mom and dad while mom is

pregnant- walking is wonderful & good to get into healthy family habits

Tummy time is great for babies as is exploration playOutside activity/ getting out of the stroller important for

toddlers!

My current prevention study

Over 850 babies are enrolled at 2 months of age and followed until they are age 2.

Doctors learn how to prevent obesity with parents

Older childrenStarting at age 2: screen BMI

• Don’t force kids to finish plates; keep portion size the size of a child’s fist

• Replace whole milk w/ lower fat milk • Limit “screen” time & eating in front

of the television! • Limit junk food and soda• Encourage active play• Substitute water and skim milk for

juice, lemonade, sweet tea, and soda.

If child is overweight?

If BMI is overweight or obese (≥85% for age) or trending upward:

• Follow advice from previous slide• Advise parents and child of weight status:

show them the BMI chart, talk about future problems related to overweight

• Protect self-esteem (make our discussion about health as much as possible)

• Arrange follow-up visit (schedule a lot of time)

Toolkit Study• Improvements from baseline to 3 months:– < 3 servings of fruits or vegetables (45%->33%)– 1 or fewer sugary drinks (30% -> 50%) – 1 or fewer unhealthy snacks (53%-> 73%)– Skim or 1% milk (12%-> 25%) – 2 or fewer hours screen time (49%-> 67%)

Weight perceptions

• At baseline, 100% of parents of healthy weight children correctly perceived their child's weight; only 56.5% of parents of overweight children did (p < .001, t test).

• At 3-month follow-up, 74.1% of parents of overweight children had an accurate perception of their child's weight, a statistically significant improvement from baseline (p < .05, t test).

Conclusions of my research and clinical work

• Parents and doctors do not visualize early concerning weight trajectories

• Providers would benefit from tools that help their self-efficacy, screening, and ways to motivate families to adopt healthy lifestyles.

• Color-coded BMI charts may help doctors communicate weight status, particularly to those of lower literacy.

• Parents would appreciate sensitive, yet straightforward, tailored communication from providers who know them well.

Thank you. I’d like to especially acknowledge many local mentors and collaborators:

Cynthia Bulik, PhDAlice Ammerman, RD, DrPH

Peggy Bentley, PhDMichael Steiner, MDAsheley Skinner, PhD

Arlene Chung, MD, MPH, MHASuzanne Lazorick, MD, MPH

Julie Jacobson Vann, RN, PhDRussell Rothman, MD, MPP

Shonna Yin, MD, MPHLee Sanders, MD, MPH

Anna Maria Fernando-Hernandez, PhD

FUNDING SOURCES:NIH/NICHD R01 HD059794NIH/NICHD 5 K23 HD051817UNC CTSA UL1RR025747

Time Trends in Parental Report of Having Been Told Their Overweight/Obese Child was Overweight/Obese

1999-2000

2001-2002

2003-2004

2005-2006

2007-2008

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Very obese (p=0.020)Obese (p=0.753)Overweight (p<0.001)All (p<0.001)