Childhood Obesity

1. Childhood Obesity

2. Introduction. • What is Overweight & Obesity? • Childhood obesity is one of the most serious public health challenges of the 21st century. The problem is global and is steadily affecting many low- and middle-income countries, particularly in urban settings. The prevalence has increased at an alarming rate. In 2007, an estimated 22 million children under the age of 5 years were overweight throughout the world. More than 75% of overweight and obese children live in low- and middle-income countries. • Causes? • The fundamental causes behind the rising levels of childhood obesity are a shift in diet towards increased intake of energy-dense foods that are high in fat and sugars but low in vitamins, minerals and other healthy micronutrients, and a trend towards decreased levels of physical activity. Medical research carried out to help determine the genetic cause of obesity is yet a relatively new field of research however a medical research by Loos, et al, (2003) • Consequences? • Overweight and obese children are likely to stay obese into adulthood and more likely to develop noncommunicable diseases like diabetes and cardiovascular diseases at a younger age. Overweight and obesity, as well as their related diseases, are largely preventable. Prevention of childhood obesity therefore needs high priority. World Health Organization (2009).

3. Recent Trends. • Prevalence within different nations, socio-economic, cultural, gender issues, … • Back this up with graphs and statistics. (last 20 year developments) • Hypotheses involved in assessing childhood obesity (set-point / fat cell theory) • Somatotypes. UK Statistics: In 2006, 16% of children aged 2 to 15 were classed as obese. This represents an overall increase from 11% in 1995. Despite the overall increase since 1995, the proportion of girls aged 2 to 15 who were obese decreased between 2005 and 2006, from 18% to 15%. There was no significant decrease among boys aged 2 to 15 over that period. Among children aged 2 to 10, 15% were classed as obese in 2006. • Boys were more likely than girls to be obese (17% compared to 15%). Which is not a common finding • Of children aged 8 to 15 who were classed as obese, two thirds (66%) of girls and 60% of boys thought that they were too heavy. (NHS, 2006)

4. National Statistics. In 2006, boys were more likely than girls to meet the recommended levels of physical activity with 70% of boys and 59% of girls reporting taking part in 60 minutes or more of physical activity on all 7 days in the previous week. • During 2006/07, 86% of pupils took part in at least two hours of high quality PE and sport a week, a gradual increase since 2003/04 when the figure was 62%. (HSE, 2006) Summary • Increasing obesity from 1995-2006 whilst overweight has remained similar. (2006 3/10 children obese or obese) • Girls in the lowest income quintile were two and half times more likely to obese than high income counterparts. • Children in households where the reference person had a semi-routine or routine occupations were nearly twice as likely to be obese compared with those in managerial and professional households. • Girls living in overweight or obese households more likely to be overweight or obese. Parental BMI does not correlate as well with boys. • Scotland found a higher rate of obesity among boys than in England, little difference found in girls.

5. National Statistics (2). • Boys were more likely than girls to meet the recommended levels of physical activity. Participation levels amongst boys remained broadly consistent with age while for girls participation generally decreased with age. • Information on participation rates showed that for boys active play (biking, football, running etc) was the most common reported activity, whilst for girls walking was the most common activity. • Parental physical activity levels were associated with children’s physical activity levels. • Seven in ten pupils achieved at least 2 hours of physical activity a week as part of their curriculum. Those in years 10 and 11 were the least likely to participate in 2 hours of PE as part of the curriculum. (HSE, 2006) • These findings correlate well with other findings such as the National Statistics Survey (2005). Again using the UK National BMI percentile classification. Which is based upon six countries averaged data The limitations of the international definitions, due to averaging data from different countries and the choice of reference age, need to be known. The UK cut-off points here presented are compatible with the current UK reference curves.

6. UK BMI Table for Children.

7. Socio-demographics www.dh.gov.uk (2009)

8. Across the Globe. (BBC, 2009)

9. Main Body. • What is overweight & obesity? • Overweight and obesity are defined as ''abnormal or excessive fat accumulation that presents a risk to health''. • Children aged 0 -5 years. (WHO Child Growth Standards) • WHO Multicentre Growth Reference Study (MGRS) – developed 1997-2003. (The MGRS collected primary growth data and related information from approximately 8500 children from widely different ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA). • How can this be quantified? • ::Length/height-for-age::Weight-for-age::Weight-for-length::Weight-for-height::Body mass index-for-age (BMI-for-age)::Head circumference-for-age::Arm circumference-for-age ::Sub scapular skinfold-for-age::Triceps skinfold-for-age::Motor development milestones • 5 – 19 years. (Growth Reference Data). • Methods • Data from the 1977 National Centre for Health Statistics (NCHS)/WHO growth reference (1–24 years) were merged with data from the under-fives growth standards’ cross-sectional sample (18–71 months) to smooth the transition between the two samples. State-of-the-art statistical methods used to construct the WHO Child Growth Standards (0–5 years), i.e. the Box-Cox power exponential (BCPE) method with appropriate diagnostic tools for the selection of best models, were applied to this combined sample. • Findings • The merged data sets resulted in a smooth transition at 5 years for height-for-age, weight-for-age and BMI-for-age. For BMI-for-age across all centiles the magnitude of the difference between the two curves at age 5 years is mostly 0.0 kg/m² to 0.1 kg/m². At 19 years, the new BMI values at +1 standard deviation (SD) are 25.4 kg/m² for boys and 25.0 kg/m² for girls. These values are equivalent to the overweight cut-off for adults (> 25.0 kg/m²). Similarly, the +2 SD value (29.7 kg/m² for both sexes) compares closely with the cut-off for obesity (> 30.0 kg/m²). • Conclusion • The new curves are closely aligned with the WHO Child Growth Standards at 5 years, and the recommended adult cut-offs for overweight and obesity at 19 years. They fill the gap in growth curves and provide an appropriate reference for the 5 to 19 years age group. • The links below provide access to the reference charts and tables by indicator: • ::BMI-for-age (5-19 years)::Height-for-age (5-19 years)::Weight-for-age (5-10 years)

10. Main Body (2). • The WHO Child Growth Standards provide a technically robust tool for assessing the well-being of infants and young children. They were derived from children who were raised in environments that minimized constraints to growth such as poor diets and infection. In addition, their mothers followed healthy practices such as breastfeeding their children and not smoking during and after pregnancy. The standards depict normal early childhood growth under optimal environmental conditions and can be used to assess children everywhere, regardless of ethnicity, socioeconomic status and type of feeding. Replacing the NCHS/WHO growth reference, which is based on children from a single country, with one based on an international group of children recognizes the fact that children the world over grow similarly when their health and care needs are met. In the same way, linking physical growth to motor development underscores the importance of looking at child development comprehensively. Together, three new elements — a prescriptive approach that moves beyond the development of growth references towards a standard, inclusion of children from around the world, and links between physical growth and motor development — provide a solid instrument for helping to meet the health and nutritional needs of the world’s children. • Current UK Policy – Early years, healthy start, sure start, and other school based initiatives. • Policy Priorities – (For George).

11. Main Body (4). • Why does it matter? • cardiovascular diseases (mainly heart disease and stroke); • diabetes; • musculoskeletal disorders, especially osteoarthritis; and • certain types of cancer (endometrial, breast and colon). • These include problems with the joints and bones (such as slipped femoral epiphysis and bow legs), a condition called benign intracranial hypertension that produces headaches and affects vision, hypoventilation (leading to drowsiness during the day, snoring and even heart failure), gall bladder disease, polycystic ovary syndrome, high blood pressure, high levels of blood fats and diabetes. • There are also marked psychological effects leading to low self-esteem. • At least 2.6 million people each year die as a result of being overweight or obese. • What are the causes? • A global shift in diet towards increased intake of energy-dense foods that are high in fat and sugars but low in vitamins, minerals and other healthy micronutrients; • A trend towards decreased physical activity levels due to the increasingly sedentary nature of many forms of recreation time, changing modes of transportation, and increasing urbanization.

12. Main Body (Consequences).

13. Main Body (3). • The concept of energy balance? • Energy Intake (Nutritional) - Fat, G.I., Sugar & sugar sweetened soft drinks, energy density & satiety, and ‘fast’ food & portion size. (Comparison of French, Mediterranean, & Italian diets). • Energy Output (Physical) – School Sport, Walking to school, Cycling to school, sedentary pastimes, • This is the factor that we are concerned with today. Healthy eating is of the utmost importance but only half the equation.

14. Main Body (…) • Exercise Prescription for obese children – • (AHA / American Academy of Paediatrics – 60 minutes of vigorous-moderate activity each day). • 65%-80% of MHR. • Family influence is significant in making adequate long term adherence factors. • Encourage him/her to walk to school or the shops, rather than always going by car or bus. • Try to get the whole family involved in activities such as bike rides and swimming. You could suggest going to the park for a game of football, cricket or Frisbee. • Visit a local leisure centre to investigate sports and team activities your child could get involved in. Guides and Scouts are a good way to get your child involved in group activities and exercise. • Make exercise into a treat by taking special trips to an adventure play park or an ice skating rink, for example. • Encourage active playtime activities such as dancing or skipping. • Physically inactive pastimes, such as watching television or playing computer games, should be limited to less than two hours a day. Encourage your child to be selective about what he/she watches to reduce the amount of time spent watching television.

15. Main Body – Types of Exercise. • Cardio vs. Resistance – Resistance training has been found by Research Digest (2007; Sothern et al.,1999) to be a viable method of training to improve health, fitness and QoL. (Long term research is necessary) – Consider Table 2. • A review by Sports Medicine author Watts et al., (2005) found that vascular improvements outweighed direct weight loss. Also that the preservation of lean body mass is crucial as it accounts for 80% of RMR. (Improvements in endothelial function > decreases atherosclerosis). Increased insulin sensitivity (Nassis et al., 2005).

16. Main Body – Types of Exercise (2). • Key points on exercise – adherence, consistency, and FUN. • Less focus upon on mode of exercise & intensity. • Maintaining weight loss is the challenge. • Any activity is good. • Aim for children is FUN and enjoyment. • Aiming to monitor activity is a difficult process, direct observation is generally the best method according to a review by Sirard & Pate (2001), but can be difficult across long periods so accelerometers are a promising alternative.

17. Main Body (Critical Analysis). • So is exercise enough? The general consensus is no, take for example the concept of energy balance – Deckelbaum & Williams, (2001). Wrote that in an average 165 kg (75 lb) child expenditure equalled, 90, 525, 135, & 180 for bicycling, running, walking & dancing respectively, and that a regular McDonalds meal equated to ~600 calories and super sized meals ~1800 calories. These numbers show that to cover these requirements would take a significant proportion of time to achieve a balance. • The necessary requirement is to prevent within the early stages of development, Denghan et al., (2005) recommendations are adequate but how realistic? Some interventions strategies that could be considered for prevention of childhood obesity I. Built environment     1. Walking network          a. Footpaths (designated safe walking path)          b. Trails (increasing safety in trails)     2. The cycling network          a. Roads (designated cycling routes)          b. Cycle paths     3. Public open spaces (parks)     4. Recreation facilities (providing safe and inexpensive recreation centers)II. Physical activity     1. Increasing sports participation     2. Improving and increasing physical education time     3. Use school report cards to make the parents aware of their children's weight problem     4. Enhancing active modes of transport to and from school          a. Walking e.g. walking bus          b. Cycling          c. Public transportIII. TV watching     1. Restricting television viewing     2. Reducing eating in front of the television     3. Ban or restriction on television advertising to children

18. Main Body (Critical Analysis) (2). • Studies on decreased sedentary behaviours as an adjunct within treatment have shown great promise (Epstein et al., 2000). A 2 year study offered increased aerobic fitness, and lowered % body fat. • School based interventions are an excellent way of aiding treatment as children spend a huge % of time in the taught environment. Conflicting evidence from OFSTED reports claim partnerships schools are raising the standard (TeacherNet, 2009) with schools meeting targets at faster rates than expected with the 5 hours per day target in 2010 coming ever closer. So can it be sustained or are misreporting of data effecting these outcomes according to opposition party (Lib Dems, 2009). • Targeting younger children has been shown to be more effective long term results in preventing weight gain as weight loss is more difficult with adolescents, due to eating patterns and P.A behaviour becoming more difficult to change as age progresses (Carter, 2002). • Active Commuting to School initiatives. • Fat consumption has decreased over the last decade, but still obesity is rising, pre-disposition through genetics is inherent which causes a cycle of juvenile obesity with accompanying low PA levels. • We can learn from studies across the Atlantic a representative sample of Canadian children (n=7216), Tremblay & Willms, (2003) studied the links between P.A., obesity & overweight & sedentary behaviours with SES, and family backgrounds. It positively identified low SES and single parent families, along with sedentary behaviours. Contrary to this Wang (2001) found that it varies internationally. • Consensus is drawn to parent and school initiatives, with children & schools in low income areas receiving priority to reduce socioeconomic inequalities in health (Veugelers & Fitzgerald, 2005)

19. Future Research. • What can be done? Action & Prevention. (Change 4 Life, NHS 2009) • Overweight and obesity, as well as related noncommunicable diseases, are largely preventable. • It is recognized that prevention is the most feasible option for curbing the childhood obesity epidemic since current treatment practices are largely aimed at bringing the problem under control rather than effecting a cure. The goal in fighting the childhood obesity epidemic is to achieve an energy balance which can be maintained throughout the individual's life-span. • increase consumption of fruit and vegetables, as well as legumes, whole grains and nuts; • limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats; • limit the intake of sugars; and • be physically active - at least 60 minutes of regular, moderate- to vigorous-intensity each day that is developmentally appropriate and involves a variety of activities. More activity may be required for weight control.

20. Future Research (2). • Maintaining a healthy weight • In most cases, experts recommend that overweight children should not be encouraged to actually lose weight. Instead they should be encouraged to maintain their weight, so that they gradually "grow into it" as they get taller. • Children should never be put on a weight loss diet without medical advice as this can affect their growth. Unregulated dieting - particularly in teenage girls - is thought to lead to the development of eating disorders. • There isn't much evidence for the best ways to treat weight problems in children, but research indicates that focusing on making long-term improvements to diet and increasing physical activity may be the effective solution. • Helping children to achieve and maintain a healthy weight involves a threefold approach that encourages them to: • eat a healthy, well-balanced diet • make changes to eating habits • increase physical activity - in 2004 the Chief Medical Officer recommended at least 60 minutes of at least moderate physical activity a day for children • The good news is that it is probably easier to change a child's eating and exercise habits than it is to change an adult's. (www.bupa.co.uk, 2009)

21. Conclusion. • Role of ParentsRole of SchoolsRole of Member StatesRole of WHORole of Civil Society and NGOsRole of the Private Sector ‘interventions at the family or school level will need to be matched by changes in the social and cultural context so that the benefits can be sustained and enhanced. Such prevention strategies will require a coordinated effort between the medical community, health administrators, teachers, parents, food producers and processors, retailers and caterers, advertisers and the media, recreation and sport planners, urban architects, city planners, politicians and legislators’. (BMA, 2009)

22. Conclusion (2). • Home Set aside time for Healthy meals Physical activity Limit television viewing • School Fund mandatory physical education Establish stricter standards for school lunch programmes Eliminate unhealthy foods—e.g., soft drinks and candy from vending machines Provide healthy snacks through concession stands and vending machines • Urban design Protect open spaces Build pavements (sidewalks), bike paths, parks, playgrounds, and pedestrian zones • Health care Improve insurance coverage for effective obesity treatment • Marketing and media Consider a tax on fast food and soft drinks Subsidise nutritious foods—e.g., fruits and vegetables Require nutrition labels on fast-food packaging Prohibit food advertisement and marketing directed at children Increase funding for public-health campaigns for obesity prevention • Politics Regulate political contributions from the food industry (Ebbeling et al., 2002)

23. Reference List. • Baird, J., Fisher, D., Lucas, P., Kleijnen, J., Roberts, H., and Law, C. (2005). Being big or growing fast: systematic review of size and growth in infancy and later obesity • Cole, T.J., Bellizzi, M.C., Flegal, K.M., & Dietz, W.H. (2000). Establishing a standard definition for child overweight and obesity worldwide: international survey. British Medical Journal. 320, 1240. • Deckelbaum, R.J., & Williams, C.L. (2001). Childhood Obesity: The Health Issue. Obesity Research.9, s239–S243 • Ebbeling, C.B., Pawlak, D.B., & Ludwig, D.S. (2002). Childhood obesity: public-health crisis, common sense cure. The Lancet. 360, 473-482. • Funatogawa, I., Funatogawa, T., & Yano, E. (2008). Do overweight children necessarily make overweight adults? Repeated cross sectional annual nationwide survey of Japanese girls and women over nearly six decades • Kipping, R.R., Jago, R., & Lawler, D.A. (2008). Obesity in children. Part 1: Epidemiology, measurement, risk factors, and screening. British Medical Journal. 337, 1824. • Lagstrom, H., Hakanen, M., Niinikoski, H., Viikari, J., Ronnemaa, T., Saarinen, M., Pahkala, K., Simell, O. (2008). Growth Patterns and Obesity Development in Overweight or Normal-Weight 13-Year-Old Adolescents: The STRIP Study. Pediatrics 122: e876-e883

24. Reference List (cont). • Must, A., and Strauss, R.S. (1999). Risks and consequences of childhood and adolescent obesity. International Journal of Obesity. 23, s2-s11. • Scharoun-Lee, M, Kaufman, J S, Popkin, B M, Gordon-Larsen, P (2009). Obesity, race/ethnicity and life course socioeconomic status across the transition from adolescence to adulthood. J. Epidemiol. Community Health 63: 133-139 • Wardle, J., Henning-Brodersen, N., Cole, T.J., Jarvis, M.J., and Boniface, D.R. (2006). Development of adiposity in adolescence: five year longitudinal study of an ethnically and socioeconomically diverse sample of young people in Britain. British Medical Journal. 332, 1130-1135. • Whitaker, R.C., Wright, J.A., Pepe, M.S., Seidel, K.D., & Dietz, W.H. (1997). Predicting Obesity in Young Adulthood from Childhood and Parental Obesity. New England Journal of Medicine, 337, 869-873. • Jotangia, D. Moody, A. Stamatakis, E. Wardle, H. (2005) ‘Obesity among children under 11’ Date Retrieved on 9/04/2009 from the World Wide Web: http://www.erpho.org.uk/Download/Public/12227/1/ObesityAmongChildrenUnder11.pdf. • Loos, R.J.F. Bouchard, C. (2003) ‘obesity- Is it a genetic disorder’ Journal of internal medicine, 254, .401-425