An Ounce of Prevention is worth a pound

1. An Ounce of Prevention is worth a pound Shaping Habits That Shape Obesity Ohio Chapter, American Academy of Pediatrics Ohio Department of Health Ohio Dietetics Association

2. Obese 1/3 (30.6%) Overweight 2/3 (65.7%) Extreme obesity (5.1%) Prevalence of Obesity U.S. Adults: 2001-2 All ages Both sexes All ethnic groups All socioeconomic levels Source: Hedley et al. 2004; Freedman et al. 2002

3. Prevalence of Overweight in U.S. Children: 2002 Age, yrs 2-5 6-11 12-19 All 6-19 At Risk (> 85%) (%) 22.6 31.2 30.9 31.0 Overweight (> 95%) (%) 10.3 15.8 16.1 16.0 * Overweight among non-Hispanic Black (20.5%) and Mexican-American (22.2%) increased much more rapidly than among whites between NHANES in ‘88-94 and 2002 Source: Hedley et al. 2004

4. Obesity Among African-American Adults: 2002 Age, yrs Males 20-39 40-59 Females 20-39 40-59 Overweight BMI > 25 % 55.4 65.0 70.3 81.5 Obese BMI > 30 % 24.7 29.7 46.6 50.6 Extreme BMI > 40 % 4.1 2.9 11.8 15.1 Source: Hedley et al. 2004.

5. Overweight Status of African-American Children: 2002 Percentile Males 85 95 Females 85 95 All Ages % 31.0 17.9 40.1 23.2 2-5 yrs % 23.2 8.0 25.6 9.6 6-11 yrs % 20.9 17.0 37.9 22.8 12-19 yrs % 32.1 18.7 41.9 23.6 Source: Hedley et al. 2004.

6. Class 3 = BMI > 40 2-fold higher risk of mortality than BMI 30 High likelihood of bariatric surgery Those over age 20 yrs In population 4.9% In black females 13.5% Class 3 Obesity in the U.S.1990 through 2000 BMI <25 50 25-29.9 30-34.9 10 Prevalence, % 5 35-39.9 >40 1 1990 1992 1994 1996 1998 2000 Year Prevalence increased 3-fold in only a decade and continues to rise

7. Psychosocial Cardiovascular Lipidemia Diabetes mellitus Hypertension Respiratory Cardiac Medical Polycystic ovary disease Gall bladder disease Osteoarthritis Cancer Pregnancy and postpartum ??? Mortality Medical Consequences of Obesity Diseases that begin in childhood amplify morbidity – and costs Source: Krebs & Jacobson 2003; Dietz 1998a; Dietz 1998b; Must 2003.

8. Prevalence of Diabetes in US Has Risen Dramatically –1990 to 2001 And how many overweight adults and kids have pre-diabetes? Source: Narayan et al. 2003; Sinha et al. 2002; Weiss et al. 2003.

9. If diagnosed at age 40 years White male: 1.01 yrs female: 13.5 yrs Hispanic male: 11.5 yrs female: 12.4 yrs Black male: 13.0 yrs female: 17.0 yrs If diagnosed at age 10 years White male: 16.5 yrs female: 18.0 yrs Hispanic male: 19.0 yrs female: 16.0 yrs Black male: 22.0 yrs female: 23.0 yrs Life-Years Lost from Diabetes in the US Source: Narayan et al. 2003

10. “Because of the increasing rates of obesity, unhealthy eating habits, and physical inactivity,we may see the first generation that will be less healthy and have a shorter life expectancy than their parents” Richard H. Carmona, MD, MPH, FACS Surgeon General U.S. Dept of Health and Human Services, 2004

11. Obesity Risk Increases with the Age of the Child • Obese at 6 years • 50% risk of obesity at 35 yrs • Obese at 10 years • 70 - 80% risk Obesity is a pediatric disorder with adult consequences Source: Bray 2002, Dietz 1998a, Dietzs 1998b,Guo et al. 2002; Kvaavik et al. 2003; `Must 2003, Whitaker et al. 1997;

12. The State of Ohio’s TeensYouth Risk Behavior Survey 2003 • 57% participate in organized after-school activities • 68% reported participating in vigorous activity in any given week; only 41% attend PE classes • 32% watch 3 or more hours of TV per average school day • 14% report being overweight, up from 10% in 1999 • 30% report eating fruits one or more times per day in the past week • 38% report eating vegetables one or more times per day in the past week (includes potatoes) • 20% report drinking the recommended 3 glasses per day of milk Source: Bray 2002; Ohio Dept of Health: www.odh.state.oh.us

13. Nutritional Gaps in U.S. Children % Children Consuming Daily Recommended Intake Critical Age Iron Phosphorus Zinc Vitamin C Vitamin A Magnesium Folate Calcium NHANES, CFSII data compiled by Dr. John Lasekan, Ross Labs

14. Children grow up In 3 environments HOME COMMUNITY SCHOOL

15. The issue of obesity Is multifactorial but parents, especially mothers, have an opportunity to create a healthful home environment

16. Babies are Getting Bigger Births > 37 wks GA Source: Kramer 2002

17. Babies Are Getting BiggerAnd Moms Are the Reason • McGill University database 1978-1996 • Mean birth weight and z-score increased over two decades (p < 0.0001) • No trends in premie birth weights • Prepregnancy obesity: from 4.7 to 10.6% • Gestational diabetes: a 20-fold increase

18. Prenatal • Maternal weight gain • An important predictor of later obesity in the child • Breastfeeding • Encourage breastfeeding • Lower incidence of obesity in breastfed infants

19. Is Breastfeeding Protective against Obesity Later in Life? • Von Kries, 1999 German 5-6 yr olds • Hediger, 2001 US 3-5 yr olds • Gillman, 2001 US 9-14 yr old • Liese, 2001 German 9-10 yr old • Armstrong, 2003 Scottish 3-4 yr olds • Bergman, 2003 German 6 yr olds • Toschke, 2003 Czech 6-14 yr old

20. Healthy People 2010 Breastfeeding Recommendations • Increase the proportion of mothers who breastfeed to 75% in the postpartum period • Increase rates to 50% at 6 mos • Increase rates to 25% at 12 mos

21. In-Hospital Breastfeeding Rates1965-2001 69.5% 61.9% 51.5% 55.0% 46.3% 43.5% 24.7% 21.7%

22. Breastfeeding Rates at 6 Months1971-2001 32.5% 27.1% 17.6% 19.8% 17.2% 10.4%

23. Largest Increases in In-Hospital Breastfeeding1996-2001 Demographic African American < 20 yrs of age WIC participant 20-24 yrs of age High school education National 1996 37.1 43.3 46.6 52.7 49.2 59.2 2001 52.9 57.2 58.2 65.9 61.1 69.5 % Change 42.6 32.1 24.9 24.5 24.2 17.4 Source: Ryan 2002

24. Obesity (Pre- or In-Pregnancy Weight) Threatens Breast-feeding (BF) • Pediatric & Pregnancy Nutrition Surveillance Surveys • 51,329 women and babies • Pregnant and gestational weight gain + BF • Both pre- and in-pregnancy obesity resulted in: • Less initiation of BF • Shorter duration of BF • Increasing obesity may threaten recent gains in breast-feeding Source: Li 2003

25. How do We fix The Problem? Train parents in how and what to feed their baby

26. Where Do Parents Look for Nutrition Information? • #1 Pediatrician/ Family MD • Social environment • Magazines • Internet • Dietitian • TV • Nutrition Center • Food labels • Media Source: Van Dillen 2003

27. The 12 Well-Child Visits 8 11 4 12 7 3 9 2 5 6 10 Anticipate problem feeding and activity practices

28. Newborn/First Visit • For Breastfed and Formula Fed Infants • Help sustain breastfeeding by building skills and offering resources for support • Iron-based formulas only • Hunger and satiety cues • Babies should regulate their own intake • Crying does not always represent hunger • It is normal for 1-3 month old babies to cry up to 3 hours per day

29. How are Infants Fed? Milk Feeding 2000 Source: Ryan et al. 2002

30. 53 kcal/100ml 67 kcal/100 ml 100 kcal/100 ml Infants Adjust Their Calories 200 180 160 Volume of Intake (mL/kg/day) 140 120 100 130 By 6 weeks, the baby regulates its own energy intake 120 Calorie Intake (kal/kg/day) 110 100 90 8 14 28 42 56 84 112 Age (days) Source: Fomon 2004.

31. From birth to 24 months, the child assumes the eating habits of the family The Feeding Infants And Toddlers Study (FITS) Source:Dwyer, 2004

32. FITS Study Methodology • Adds critical information to augment NHANES, CFSII, Ross Mother’s Survey information • 5 Gerber sponsored FITS surveys over 30 yrs • Snapshot of eating habits in first 2 years (2002) • Random sample of 3022 (Experian database) • Recruitment and household review • 24-hr dietary recall and subject information • Second dietary recall for subset (n=703) • Response rate for recalls 94% Source: Devaney et al. 2004a

33. Examined transitional times for feeding 4-6 months 7-11 months 12-24 months Diets found to vary widely day-to-day Nutrition is good over the first 24 months Exceeds adequate intake for all nutrients, 0-12 months and almost all nutrients, 12-24 mos Vitamin E low 12-24 mos Fiber low in toddlers But energy intake exceeds Estimated Energy Requirement (EER) at all ages FITS: Nutrient Intakes 0-24 months of age Source: Devaney et al. 2004 b

34. Energy intake exceeds EER 4-6 mo 10% 7-11 mo 23% 12-24 mo 31% Feeding Breast < EER BF/ formula = EER Formula > ERR Solids and cereals add to energy intakes, especially when coupled with formula Energy Intake Infants and Toddlers

35. Two-Month Visit • Infant Feeding • Set expectations: • the baby will increase to 24-28 oz/day over the next 2 months • Provide 4 oz four to six times per day • No cereal, no baby food, no juices • Nothing added in the bottle

36. Not all Crying Needs FoodTwo Months • Learn to interpret the infant’s cries • Parents eager to “empty the bottle” encourage overeating • Satiety cues between 4-12 weeks: • Turns head away or releases nipple • Falls asleep • Comfort the baby • Rocking, massaging, cuddling, or listening to music

37. Recommendations for Iron • Healthy People 2010: “…reduce iron-deficiency among children aged one to two years to 5%” • AAP Committee on Nutrition • Supplement breastfed infants with iron • Iron-fortified formula is the appropriate substitute for breastfeeding in the first 12 months • Iron fortified infant cereals and grains, as well as meats are important sources of iron, especially for infants who continue to breastfeed beyond 6 months of age

38. Physical ActivitiesTwo Months • Minimize stationary devices • Use crib mobiles • Encourage reaching, kicking, stretching, and belly play time • No T.V.

39. 4-Month Visit • The addition of cereal • No solids until developmentally ready to use a spoon, usually 4-6 mos of age • Cereal only with a spoon, not in the bottle • Start a single grain, iron-fortified cereal • Portion: increase to 1-2 Tbsp twice daily • First baby food: vegetables at 6 mos

40. Excessive Juice is a Risk for Obesity • Both short stature and obesity are tied to excessive intake of juices • Only 100% juice • Only after 6 months of age • Only from a cup, not from a bottle • Limit to 3 oz initially with a maximum of 4-6 oz / day for 1-6 year olds

41. Fail to consume vegetables as a discrete food: 9-11 months 27 % 12 months 18-23% Dark Green Vegetables are consumed by fewer than 10% of toddlers Deep yellow vegetables decrease from 39% at 9 mos to 14% at 18 mos Potatoes – consume daily 4-6 mos 3.6% 7-8 mos 12.4% 9-11 mos 24.1% 12-14 mos 33.2% 15-18 mos 42.0% 19-24 mos 40.6% By 24 mos 25% of toddlers consume fried potatoes on any day Promote Vegetables for Infants & Toddlers Source: Fox et al. 2004

42. Feeding the Baby • Infants innately prefer sweet and salty. • Infants may reject bitter and sour • Infants tend to resist new foods (neophobic)

43. Implications… • More than 10 exposures may be needed to establish a new food. • Children like and eat what is familiar • Parental eating habits influence the baby’s choices at this age

44. Physical ActivitiesFour Months • Non-restrictive play • Belly play time • Sits with support • Reaches and holds objects • Play gyms • No TV

45. Top 5 FruitsFITS Study, 2004 Source: Fox et al. 2004

46. Six-Month Visit • Start vegetables and offer first at each meal • Add one new food every 3-4 days • Portion sizes • Cereal 2-4 tablespoons twice per day • Vegetables 2 tablespoons twice per day • Fruits 2 tablespoons twice per day

47. Meats & Proteins for Infants & Toddlers Source: Fox et al. 2004

48. Common Early Feeding Traps • Anticipate that daily milk intake will fall as baby’s food intake increases • Avoid “combo dinners” and baby desserts • The extrusion reflex is normal and does not mean that the baby doesn’t like the food • New foods require multiple presentations • Focus on new eating experiences and skills

49. Physical Activities Six Months • Minimize stationary devices • Sits without support • Starting to crawl • First signs of independent mobility • No T.V. until after 24 months of age

50. Nine-Month Visit • Offer many new foods and textures • Introduce a cup as the diet advances • Discuss choking hazards • Never use food as reward or bribe • Offer variety: finger and table foods • New food types and textures • Veggies & fruits at every meal • Establish a variety of meats Aim to Develop Self-feeding Skills