Obesity Advocacy

1. Obesity Advocacy Sandra Hassink, MD, FAAP Chairperson, Obesity Leadership Workgroup Jeanne Lindros, MPH Manager, Obesity Initiatives

2. Disclosure Statement

3. Why

4. National Perspective www.ncsl.org/.../programs/health/ObesityMap.jpg The National Survey of Children's Health, Overweight and Physical Activity Among Children: A Portrait of States and the Nation 2005; HRSA,Health, United States, U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, National Center for Health Statistics, 2007.

5. The 2007 national Youth Risk Behavior Survey (High School Students) 13% Obese Unhealthy Dietary Behaviors 79% ate fruits and vegetables less than five times per day during the 7 days before the survey. 34% drank a can, bottle, or glass of soda or pop (not including diet soda or diet pop) at least one time per day during the 7 days before the survey. Dietary Patterns

6. Physical Activity Patterns The 2007 National Youth Risk Behavior Survey (High School Students) 65% did not meet recommended levels of physical activity 46% did not attend physical education classes. 70% did not attend physical education classes daily. 35% watched television 3 or more hours per day on an average school day. 25% played video or computer games or used a computer for something that was not school work for 3 or more hours per day on an average school day.

7. Health Consequences In childhood, obese children are more at risk for: Type 2 diabetes; High blood pressure; Liver disease; Dyslipidemia including high cholesterol, high triglycerides and low HDL cholesterol; Upper Airway Obstruction Sleep Apnea Syndrome; and Hip and knee problems.

8. Health Consequences In addition to the devastating physical health consequences, overweight and obese children suffer social and emotional health consequences as well. Obese children: have lower self-esteem; are more likely to be depressed; suffer from bullying and teasing; and have lower academic achievement.

9. Cost of Obesity An obese child’s healthcare costs are roughly three times more than the average child. Childhood obesity is estimated to cost $14 billion annually in direct and indirect health expenses. Children in Medicaid account for $3 billion of those expenses Annual obesity-related hospital costs for children and adolescents were $238 million in 2005, nearly doubling between 2003 and 2005.

10. Health Disparities Mexican-American and African-American children ages 6-11 are more likely to be overweight or obese than white children: 43% of Mexican-American children 37% of African-American children 32% of white children Data on Native American children is limited, but one study of the Aberdeen Area youths age 5-17 found: 48% of Native American boys were obese or overweight 46% of Native American girls were obese or overweight

11. Making the Link: Practice and Community Case Study A 12 year-old girl At her 12 year well check mother reports her daughter’s increasing comments about her weight and being “fat”. BMI = 23, 90th percentile for a 12 year-old girl Identified as overweight

12. Community/Social/Demographic Ethnicity Parenting Styles Socioeconomic Status School Lunch Program Child Feeding Practices Peer/ Sibling Interactions Child Characteristics Crime Rates General Safety Foods Available In House Family TV Viewing School Schedule Child’s Weight Status age gender School Physical Education Programs Sedentary Behavior Parent Monitoring of TV Nutritional Knowledge Dietary Intake Work Hours Physical Activity Decision Making Parent Activity Patterns Parent Dietary Intake family genetics Schedule School Environment Corner Store Parent Encouragement of Activity Parent Food Preferences Parent Weight Status Family Leisure Time Activities At Home Accessibility of Convenience Foods & Restaurants Availability of Recreational Activities

13. Skips breakfast (no time) Eats pretzel and juice for lunch (not hungry for a regular lunch) After school – soda and snack food (poor choices) Dinner – Family eats out 3x/week (too busy to cook) Bedtime – Cereal (eating while watching TV) 12 Year-Old GirlDietary Patterns – Behavioral Perspective

14. Community/Social/Demographic Ethnicity Parenting Styles Socioeconomic Status School Lunch Program Child Feeding Practices Peer/ Sibling Interactions Child Characteristics Crime Rates General Safety Foods Available In House Family TV Viewing School Schedule Child’s Weight Status age gender School Physical Education Programs Sedentary Behavior Parent Monitoring of TV Nutritional Knowledge Dietary Intake Work Hours Physical Activity Decision Making Parent Activity Patterns Parent Dietary Intake family genetics Schedule School Environment Corner Store Parent Encouragement of Activity Parent Food Preferences Parent Weight Status Family Leisure Time Activities At Home Accessibility of Convenience Foods & Restaurants Availability of Recreational Activities

15. 12 Year-Old GirlDietary Patterns – Environmental Perspective Skips breakfast (school start time/availability of school breakfast) Eats pretzel and juice for lunch (school lunch) After school – soda and snack food (corner store) Dinner – Family eats out 3x/week (fast food availability) Bedtime – Cereal (TV in bedroom)

16. Community/Social/Demographic Ethnicity Parenting Styles Socioeconomic Status School Lunch Program Child Feeding Practices Peer/ Sibling Interactions Child Characteristics Crime Rates General Safety Foods Available In House Family TV Viewing School Schedule Child’s Weight Status age gender School Physical Education Programs Sedentary Behavior Parent Monitoring of TV Nutritional Knowledge Dietary Intake Work Hours Physical Activity Decision Making Parent Activity Patterns Parent Dietary Intake family genetics Schedule School Environment Corner Store Parent Encouragement of Activity Parent Food Preferences Parent Weight Status Family Leisure Time Activities At Home Accessibility of Convenience Foods & Restaurants Availability of Recreational Activities

17. 12 Year-Old Girl Physical Activity Patterns - Behavioral Perspective No outdoor time (doesn’t want to go outside) Computer, IM etc 3 hours/day (nothing else to do) Homework 2 hours/day (prefers not to do homework at study period) Weekends “TV all the time” (doesn’t know what to do if not watching TV) Extracurricular activity - Cheerleading 2x/week

18. Community/Social/Demographic Ethnicity Parenting Styles Socioeconomic Status School Lunch Program Child Feeding Practices Peer/ Sibling Interactions Child Characteristics Crime Rates General Safety Foods Available In House Family TV Viewing School Schedule Child’s Weight Status age gender School Physical Education Programs Sedentary Behavior Parent Monitoring of TV Nutritional Knowledge Dietary Intake Work Hours Physical Activity Decision Making Parent Activity Patterns Parent Dietary Intake family genetics Schedule School Environment Corner Store Parent Encouragement of Activity Parent Food Preferences Parent Weight Status Family Leisure Time Activities At Home Accessibility of Convenience Foods & Restaurants Availability of Recreational Activities

19. 12 Year-Old Girl Physical Activity Patterns - Environmental Perspective No gym this session (school schedule) No recess (school schedule) No outdoor time (neighborhood safety) Computer, IM etc 3 hours/day (family entertainment environment) Homework 2 hours/day (family scheduling) Weekends “TV all the time” (family activity) Extracurricular activity Cheerleading 2x/week

20. Community/Social/Demographic Ethnicity Parenting Styles Socioeconomic Status School Lunch Program Child Feeding Practices Peer/ Sibling Interactions Child Characteristics Crime Rates General Safety Foods Available In House Family TV Viewing School Schedule Child’s Weight Status age gender School Physical Education Programs Sedentary Behavior Parent Monitoring of TV Nutritional Knowledge Dietary Intake Work Hours Physical Activity Decision Making Parent Activity Patterns Parent Dietary Intake family genetics Schedule School Environment Corner Store Parent Encouragement of Activity Parent Food Preferences Parent Weight Status Family Leisure Time Activities At Home Accessibility of Convenience Foods & Restaurants Availability of Recreational Activities

21. Obesity in the Context of This 12 Year-Old’s Environment Interaction of environment and behavior is critical Making healthy decisions only works when there are safe and affordable healthy options readily available in the environment The next slide highlights all the factors that influence this 12 year-old’s food and physical activity environments

22. Community/Social/Demographic Ethnicity Parenting Styles Socioeconomic Status School Lunch Program Child Feeding Practices Peer/ Sibling Interactions Child Characteristics Crime Rates General Safety Foods Available In House Family TV Viewing School Schedule Child’s Weight Status age gender School Physical Education Programs Sedentary Behavior Parent Monitoring of TV Nutritional Knowledge Dietary Intake Work Hours Physical Activity Decision Making Parent Activity Patterns Parent Dietary Intake family genetics Schedule School Environment Corner Store Parent Encouragement of Activity Parent Food Preferences Parent Weight Status Family Leisure Time Activities At Home Accessibility of Convenience Foods & Restaurants Availability of Recreational Activities

23. Environment- Where Children Live Where a child lives and goes to school has a significant impact on his health Today’s food and physical activity environment make it hard to be healthy. For example: Lack of physical activity in schools (i.e. no PE or recess) Car-focused world – active transport (i.e. walking or biking) is not easy Lack of available and affordable fresh fruits and veggies Massive marketing of unhealthy food and beverages Overabundance of energy dense nutrient poor foods

24. Communities at Risk Communities at risk are neighborhoods and regions where children are more likely to be overexposed to unhealthy factors and underexposed to healthy ones. In these communities, resources are minimal, infrastructure is not conducive to physical activity, income is generally low, and economic opportunities may be scarce. The rates of obesity in communities at risk continue to rise far above those where children have access to healthy foods and places where they can engage in physical activity.

25. Exercise:Obesity Your Own Story Take a minute to complete the Healthy Lifestyles and Your Environment Exercise

26. Creating an Environmentfor Healthy Active Living • In our homes • In our own offices/workplaces • In schools • In childcare • In the community

27. Where

28. Where?

29. Who?

30. PEDIATRICIANS Take Action You can help your patients and improve your clinical care by becoming an advocate and being part of a movement to create healthy environments that foster healthy active living for all children. Children need you to be their advocates because environmental change does not occur without advocacy and children don’t have a voice in their childcare/school operations, community, and public policy. You can provide the voice and the expertise to make positive changes in the environment.

31. How? http://www.ampestsolutionsinc.com/sitebuildercontent/sitebuilderpictures/Hispanic-Family.jpg

32. Policy Opportunities: How To Take Action A variety of policy strategies exist to support healthier communities Centers for Disease Control & Prevention, Institute of Medicine, Robert Wood Johnson Foundation and AAP have identified some specific strategies that fall into the following categories: Improving access to healthy foods and beverages Limit access to unhealthy foods and beverages Improve opportunities for safe and affordable physical activity Increase active transportation through community design Improve school and childcare environments Support breastfeeding

33. Kind of Policy Changes • Change existing policy • Propose new policy • Implement existing policy • Support/Oppose a proposed policy

34. What you need to move policy? • Recognition that a problem exists • Evidence, data, stories • Strategies which address the problem • Evidence, information • Policy window of opportunity • Timing • Policy champion • Personal connections • Stories • Focusing event

35. Mapping Policy to Your Practice Introducing a new tool that helps • Connect clinical guidance with policy change at the practice, community, school, state, and federal level • Allows you to transition from your patient story to policy

36. Policy Opportunities Tool To further distill the various policy strategies, the AAP created a tool that looks at the different opportunities in terms of: existing clinical anticipatory guidance and messaging (5, 2, 1, 0,breastfeeding and BMI), and the various sectors where changes can occur (practice, community, school, state, and federal) The tool also highlights which strategies are recommended by AAP, CDC, IOM, RWJF, and/or the National Governors Association www.aap.org/obesity/matrix_1.html

37. Why your own story? • Makes it personal • Connects your Head and Heart • Can involve you in your own lifestyle change • Connects you with your own environment, facillitator and barriers • Gives you perspective, “keeps you on the ground” • Identify with your patients and family

38. Using Personal Stories and Data • Family stories give a face and heart to needs. • “Statistics are human beings with the tears wiped off.”  ~Paul Brodeur, Outrageous Misconduct • Your story and your patient’s story provide the human connection (the tears). • Data expands family stories to inform policy debates and drive change. • “At the end of the day, people change or support change for emotional reasons. Data helps them then rationalize their decisions.”

39. Using Information and Data • How many children in your community/state have what needs? • How do needs vary across community states and why? • How do needs vary across subgroups of children within and across states and why? • How does data support your assumptions or what you re hearing from the field (providers, families, other agencies)?

40. One-pagers

41. Data Sources

42. Additional Resources • AAP Websites and Tools (Federal Affairs, State and Government Affairs, Obesity, Community Pediatrics) • Let’s Move (http://www.letsmove.gov/) • Be Our Voice (www.nichq.org/advocacy) • Alliance for Healthier Generation (www.healthiergeneration.org) • Robert Wood Johnson Center to Prevent Obesity (www.reversechidlhoodobesity.org)

43. Community Resources/Movement • AAP funded obesity projects: • Alabama, Arkansas, Kentucky, Mississippi (BOV) • Kansas, New York 1, New Jersey, Oregon, Maine (HAL) • Community Pediatrics Training Initiative: • Duke University, North Carolina • Mount Sinai School of Medicine • New YorkNew York-Presbyterian Hospital/Weill Cornell Medical Center, New York • Orlando Health – Department of Pediatrics Residency Training Program • FloridaUniversity of Florida-Gainesville, Florida • Robert Wood Johnson Communities • Putting Prevention to Work Communities

44. Policy Implementation and StrategyWhat do you need? Core Elements • Knowledge • Relationships • Leadership/Team Skills • Skills to Execute Strategies

45. State versus Federal

46. State versus Federal (continued)

47. Example: School/Community Level Example: Sugar-sweetened Beverages in Schools Knowledge: • Use policy tool to get strategies and evidence • School board decision making • Issue knowledge (eg, finances of school, history of contract) • Local data • Other programs that have worked

48. Example: School/Community Level Relationships • School board members • Wellness Committee • Influential families • PTA • School staff

49. Example: School/Community Leadership Team Skills: • Ability to champion issue • Raise awareness • Gather core support • Articulate goals • Assemble team • Have passion

50. Example: Schools Community Skills to Execute: • Relationship building • Speaking skills • Media skills • Writing skills • Informal networking skills