The Childhood Obesity Epidemic Role of the Home and Family

1. The Childhood Obesity EpidemicRole of the Home and Family Kathleen Colleran, MD Associate Professor of Medicine University of NMHSC Project ECHO

2. Objectives • Understand how changes in food consumption contribute to childhood obesity • Understand how changes in environment contribute to obesity. • Understand how TV/advertising contribute to childhood obesity • Understand the role of the home/family in preventing/treating obesity

3. Today, about 16 percent of all children and teens in the United States are overweight. From the statistical sourcebook “A Nation at Risk: Obesity in the United States.” To order, call 1-800-AHA-USA1 or email inquiries@heart.org

4. Obesity-associated annual hospital costs for children more than tripled between 1979 and 1999. (Wang G, Dietz WH. Economic burden of obesity in youths aged 5 to 17 years: 1979-1999. Pediatrics 2002;109(5):E81-E86) From the statistical sourcebook “A Nation at Risk: Obesity in the United States.” To order, call 1-800-AHA-USA1 or email inquiries@heart.org

5. The possible causes • Food • Exercise • TV/advertisement

6. According to a national study, 92 percent of elementary schools do not provide daily physical education classes for all students throughout the entire school year. (School Health Policies and Programs Study. Journal of School Health 2001;71[7]) From the statistical sourcebook “A Nation at Risk: Obesity in the United States.” To order, call 1-800-AHA-USA1 or email inquiries@heart.org

7. Six out of 10 children ages 9-13 don’t participate in any kind of organized sports/physical activity program outside of school. Children whose parents have lower incomes and education levels are even less likely to participate. Nearly 23 percent don’t engage in any free-time physical activity. (Physical activity levels among children aged 9-13 years – United States, 2002. MMWR 2003;52[33]:75-8) From the statistical sourcebook “A Nation at Risk: Obesity in the United States.” To order, call 1-800-AHA-USA1 or email inquiries@heart.org

8. At least 30 minutes of moderate physical activity on most days of the week is the recommended minimum. Nearly 23 percent of children and 40 percent of adults get no free-time physical activity at all. (Physical activity levels among children aged 9-13 years – United States, 2002. MMWR 2003;52[33]:785-8) and (National Center for Health Statistics. National Health Interview Survey, 1999-2001) From the statistical sourcebook “A Nation at Risk: Obesity in the United States.” To order, call 1-800-AHA-USA1 or email inquiries@heart.org

9. The (possible) causes • Increased car travel and less person-powered transport • Increased concerns over child safety - stranger danger and traffic • Fewer walkable destinations - shops, letter boxes

10. The (possible) causes • Personal injury litigation and reduced opportunities for physical activity • More families with two working parents “Go inside and lock the door until we get home” • Parents working longer hours - too tired and too busy to play

11. The (possible) causes • Increasing opportunities for sedentary recreation • television and video • internet use and chat rooms • computer games

12. The (possible) causes • Increasing demands for better academic performance • coaching • homework • reading • computer work (not games)

13. The (possible) causes • Poor fundamental movement skills - as children participate less, they fail to develop these fundamental skills so want to participate less “The sedentary cycle”

14. Summary of Problems • the demands for achievement and safety we place on our children • the demands for (sedentary) entertainment our children place on us

15. In 1980, about 50 percent of high school seniors reported eating green vegetables “nearly every day or more.” By 2003, that figure had dropped to about 30 percent. (YES Occasional Papers. Paper 3. Ann Arbor, Mich.: Institute for Social Research, May 2003) From the statistical sourcebook “A Nation at Risk: Obesity in the United States.” To order, call 1-800-AHA-USA1 or email inquiries@heart.org

16. Between 1977-78 and 2000-01, milk consumption decreased by 39 percent in children ages 6-11, while consumption of fruit juice rose 54percent, fruit drink consumption rose 69percent and consumption of carbonated soda rose 137percent. (Cleveland L. U.S. Department of Agriculture; National Food Consumption Survey, 1977-78; What We Eat in America, NHANES 2001-02) From the statistical sourcebook “A Nation at Risk: Obesity in the United States.” To order, call 1-800-AHA-USA1 or email inquiries@heart.org

17. In 1970, about 25 percent of total food spending occurred in restaurants. In 1995, 40 percent of food dollars were spent away from home. (Paeratakul S, Ferdinand D, Champagne C, Ryan D, Bray G. Fast-food consumption among US adults and children. J Am Diet Assoc 2003:103:1332-8) From the statistical sourcebook “A Nation at Risk: Obesity in the United States.” To order, call 1-800-AHA-USA1 or email inquiries@heart.org

18. Children eat nearly twice as many calories (770) at restaurants as they do during a meal at home (420). (Zoumas-Morse C, Rock CL, Sobo EJ, Neuhouser ML. Children’s patterns of macronutrient intake and associations with restaurant and home eating. J Am Diet Assoc 2001;101-923-5) From the statistical sourcebook “A Nation at Risk: Obesity in the United States.” To order, call 1-800-AHA-USA1 or email inquiries@heart.org

19. changes in children’s food choices % consuming poor food choices by age Food 2-3y 4-7y 8-11y 12-15y snack foods 23 32 35 34 soft drinks 28 35 39 47 Fruit 77 69 59 54 Source: NNS Australia 1995 ABS 1999

20. Interrelationship of food and TV viewing and obesity • In addition to its impact on physical activity, TV viewing is associated with energy intake through increased consumption of drinks and snacks • Children of low SES families watch more TV and consume more energy than do children of high SES families, and low SES parents more often have the TV on during meals • TV viewing during meals may not only increase children’s exposure to advertising of foods, it may also limit opportunities for modelling of healthy eating

21. TV viewing and energy Significant relationships · observed between TV viewing and consumption of 10000 high energy foods (after controlling for SES): 9500 Discretionary drinks: fruit · 9000 juice drinks, cordial, cola and non - cola soft - drinks 8500 Mean of energy (kJ) per day Discretionary snacks: · 8000 doughnuts, meat pies and sausage rolls, potato crisps, extruded snacks, lollies and 7500 hot chips (French fries) 7000 Other high energy/high fat · <= 30 31-90 91-150 >= 151 foods: sausages, deli meats mins/day mins/day mins/day mins/day and sugar Time spent watching TV

22. How often is the television on during the evening meal? • Low SES parents were significantly more likely to usually have the TV on during meal times • Twice as many low SES families as high SES families (40% vs. 20%) reported that it was parents who wanted the TV on during meal times • Only 25% of mothers believed TV advertising influenced their child’s eating, and there were no SES differences %

23. television advertisements average child in USA sees over 20,000 advertisements a year viewing time food ads/hr Cals /hr Fat /hr Sugar/hr children's 12 2,590 74g 418g adult 5 1,398 62g 14g mixed 6 1,731 77g 17g

24. Effect of TV ads by ageing up to age 4 ads seen as entertainment age 6 to 7 believe ads provide information age 7–8 can’t distinguish between information and intent to persuade age 10–12 can understand motives & aims of advertising, but most still can’t adequately explain sales techniques sources: Young B (1998), Emulation, Fears and Understanding: A review of recent research on children and television advertising, ITC, London. Kunkel D Children and Advertising A Fair Game? 1994. Ward S., Wackman D. & Wartella E., (1977), How Children Learn to Buy, Beverly Hills CA: Sage, cited in Young B (1998)

25. pester power 73% of children demand advertised products 80% persist with demands when parents say ‘no’ Source: CWS Ltd 2000 Blackmail – the first in a series of inquiries into consumer concerns about the ethics of modern food production and advertising, CWS Ltd Manchester; Sustain 2000 Reaching the parts. Community mapping: working together to tackle social exclusion and food poverty. Sustain London

26. pester power The Home/Family Component

27. Why focus on family environment? • It is where (many of) our children’s eating and activity habits are learnt and reinforced • The family environment ‘mediates’ the influence of the broader environment • We have some (limited) research that supports its importance • Common sense suggests it will be important – parents want to do the best for their children

29. Some findings on the family environment • 35% parents have schedules making it difficult for families to eat the evening meal together • 30% mothers find it difficult to find time to prepare the evening meal • 15% don’t consider the evening meal to be a pleasant family time • 30% of families have the TV on during the evening meal on most nights

30. Family influences on children’s eating • A range of factors have been shown in small scale studies in the USA to influence children’s eating: • Parent-child feeding relationship • Food availability and accessibility • Media exposure • Opportunities for modeling • Few population studies conducted

31. Family influences on children’s activity • Evidence from limited number of studies in the USA • Physical environment, e.g. play space, fencing, recreational equipment • Family rules (activity and sedentary) • Parental modelling • Parental support and encouragement

32. Summary of Probelms • Almost every aspect of the way we live has the potential to contribute to reduced activity among our children • No single factor is the main cause so we need to consider and address all of the potential culprits

33. Possible solutions needed the home • set aside time for healthy meals • limit television viewing

34. Possible solutions needed changes needed schools • fund mandatory physical education • establish stricter standards for school lunch programs • eliminate unhealthy foods such as soft drinks and lollies • provide concessions on healthy snacks

35. Possible solutions needed changes needed marketing and media • consider a tax on fast food and soft drinks • subsidise nutritious foods–fruits and vegetables • require nutrition labels on fast-food packaging • prohibit food advertisement and marketing directed at children • increase funding for public-health campaigns

36. Recommendations - 1 • We need a better understanding of the role of the family environment - research is essential • We need to find ways of better supporting parents, especially first-time parents For example: • Via child and maternal health services • Via the school and education system • Via child care and child support systems

37. Recommendations - 2 • Whatever we do it must be evaluated to ensure the investment benefits our children • We need to work to co-ordinate our efforts nationally • No one-off programs – we need to look at making systemic changes that are sustained

38. Conclusions • The family environment and parenting behaviours are likely to be critically important • We currently have a poor understanding of the influence of the family environment on the development and maintenance of children’s: • Eating behaviours • Physical activity habits • Risk of childhood and adult overweight/obesity

39. New ECHO initiatives to expand access and eliminate disparities in diabetes health care • Motivational Interviewing training for ECHO participants • Virtual Community of CDEs/building CDEs • Building and supporting Diabetes Community Health Specialists