Innovative Treatment for Innovative Treatment for Pediatric Overweight: An Pediatric Overweight: An

Important Element of Important Element of Cancer ControlCancer Control

Suzanne Mazzeo, Ph.D.Suzanne Mazzeo, Ph.D.Rachel Walker, M.A.Rachel Walker, M.A.

AcknowledgementsAcknowledgements Marilyn Stern, PhDMarilyn Stern, PhD Joseph Laver, MDJoseph Laver, MD Ron Evans, PhDRon Evans, PhD Diane Wilson, EdDDiane Wilson, EdD Janet Delorme, MSJanet Delorme, MS Resa Jones, PhDResa Jones, PhD Karen Mitchell, M.S.Karen Mitchell, M.S.

Prevalence of Overweight and Prevalence of Overweight and Obesity (Adults)Obesity (Adults)

4654.4

65.7

1523.3 30.6

010203040506070

NHANES II1976-1980

NHANES III1988-1994

NHANES1999-2002

OverweightObese

Overweight vs. ObeseOverweight vs. Obese

Body Mass Index (BMI) Weight StatusBody Mass Index (BMI) Weight Status Below 18.5 --Underweight Below 18.5 --Underweight 18.5 – 24.9 -- Normal 18.5 – 24.9 -- Normal 25.0 – 29.9 -- Overweight 25.0 – 29.9 -- Overweight 30.0 and Above -- Obese 30.0 and Above -- Obese

BMI = weight (kg)/height (m)BMI = weight (kg)/height (m)22

Health Risks Associated Health Risks Associated with Obesitywith Obesity

Type-II diabetesType-II diabetes Cardiovascular disease Cardiovascular disease HypertensionHypertension StrokeStroke OsteoarthritisOsteoarthritis Sleep apneaSleep apnea CancerCancer

Obesity and CancerObesity and CancerObesity is associated with the following Obesity is associated with the following

types of cancer: types of cancer: coloncolon breast (postmenopausal)breast (postmenopausal) endometrium (the lining of the uterus)endometrium (the lining of the uterus) kidneykidney gallbladdergallbladder pancreaspancreas esophagusesophagus

National Cancer Institute

In 2002, an estimated 41,000 new In 2002, an estimated 41,000 new cases of cancer in the United States cases of cancer in the United States were due to obesity. About 3.2 percent were due to obesity. About 3.2 percent of all new cancers are linked to obesity of all new cancers are linked to obesity (1).(1).

14% of deaths from cancer in men & 14% of deaths from cancer in men & 20% of deaths in women were due to 20% of deaths in women were due to overweight and obesity(2). overweight and obesity(2).

1. Polednak AP. Trends in incidence rates for obesity-associated cancers in the U.S. Cancer Detection and Prevention 2003; 27(6):415–421.

2. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. New England Journal of Medicine 2003; 348(17):1625–1638.

Obesity and CancerObesity and Cancer

Obesity and physical inactivity may Obesity and physical inactivity may account for 25%-30% of cancer of the account for 25%-30% of cancer of the colon, breast (postmenopausal), colon, breast (postmenopausal), endometrial, kidney, and esophagus endometrial, kidney, and esophagus

Preventing weight gain can reduce the Preventing weight gain can reduce the risk of many cancers. Healthy eating risk of many cancers. Healthy eating and physical activity early in life can and physical activity early in life can prevent overweight and obesity. prevent overweight and obesity.

National Cancer Institute

Obesity and CancerObesity and Cancer

Prevalence of Pediatric Prevalence of Pediatric OverweightOverweight

0

5

10

15

20

25

Age 2-5 Age 6-11 Age 12-19

Non-HispanicWhiteNon-HispanicBlackMexican-American

Source: NHANES (Hedley et al., 2004)

Pediatric OverweightPediatric Overweight For children (anyone under 18) there are two For children (anyone under 18) there are two

categories used to define overweight based on categories used to define overweight based on Body Mass Index (BMI):Body Mass Index (BMI):

BMI is an indicator of weight status that takes into BMI is an indicator of weight status that takes into account height and weight (and age and gender, for account height and weight (and age and gender, for children).children).

““At-risk for overweight” is a term used to describe At-risk for overweight” is a term used to describe children between the 85children between the 85thth and 95 and 95thth BMI percentile. BMI percentile.

““Overweight” is used to describe children above the Overweight” is used to describe children above the 9595thth percentile. percentile.

Why is Pediatric Overweight a Why is Pediatric Overweight a Concern?Concern?

Rates are increasing rapidly—more than doubled in the Rates are increasing rapidly—more than doubled in the last 3 decades. last 3 decades.

It’s associated with numerous health problems including It’s associated with numerous health problems including high blood pressure Type 2 diabetes, asthma, and high blood pressure Type 2 diabetes, asthma, and musculoskeletal problems in childhood. musculoskeletal problems in childhood.

Overweight children are very likely to become obese Overweight children are very likely to become obese adults with associated health problems.adults with associated health problems.

They also suffer negative psychological and emotional They also suffer negative psychological and emotional consequences.consequences.

Physical ActivityPhysical ActivityCultural differences in physical activity may explain Cultural differences in physical activity may explain

ethnic disparities in obesity ratesethnic disparities in obesity rates Activity rates of adolescents from all ethnic groups Activity rates of adolescents from all ethnic groups

have decreased over the last 40 years have decreased over the last 40 years

African American girls’ physical activity median African American girls’ physical activity median activity declined 100% between ages 9-10 (year 1 of activity declined 100% between ages 9-10 (year 1 of the study) and ages 18-19 (year 10)the study) and ages 18-19 (year 10)

Caucasian adolescent girls’ median activity declined Caucasian adolescent girls’ median activity declined 64%64%

By ages 16-17, 56% of African American girls did not By ages 16-17, 56% of African American girls did not

engage in any leisure time physical activity. engage in any leisure time physical activity.

Adult interventions have had poor Adult interventions have had poor outcomesoutcomes

Treating childhood overweight is an Treating childhood overweight is an important strategy for the prevention important strategy for the prevention of adult obesity. of adult obesity.

Early InterventionEarly Intervention

TEENS ProgramTEENS Program 157 adolescents between the ages of 11 157 adolescents between the ages of 11

and 18 (and 18 (MM age = 13.6 years, 59% female). age = 13.6 years, 59% female). Majority are African American (76%)Majority are African American (76%) Average baseline BMI percentile was 99.00 Average baseline BMI percentile was 99.00

(SD=.97). (SD=.97). 1/3 (34%) had Medicaid or were uninsured1/3 (34%) had Medicaid or were uninsured 77% were still participating at 12 weeks, 77% were still participating at 12 weeks,

and 65% remained enrolled at 6 months. and 65% remained enrolled at 6 months.

Adolescent InterventionAdolescent Intervention1.1. Physical Activity InterventionPhysical Activity Intervention

monitored, structured physical activity session one monitored, structured physical activity session one day each week day each week

two additional days of physical activity at YMCAtwo additional days of physical activity at YMCA

2.2. Behavioral InterventionBehavioral Intervention intake behavioral specialist intake behavioral specialist bi-weekly, ongoing, structured, same gender groupsbi-weekly, ongoing, structured, same gender groups homework is assigned and goal monitoring t homework is assigned and goal monitoring t

3.3. Nutrition InterventionNutrition Intervention 30 minute twice-monthly meetings with the dietitian30 minute twice-monthly meetings with the dietitian

A New ApproachA New Approach

Our intervention will incorporate an Our intervention will incorporate an intensive parental intervention intensive parental intervention within an established adolescent within an established adolescent program (TEENS Program).program (TEENS Program).

Why Parents?Why Parents?1)1) parental obesity is associated with parental obesity is associated with

overweight status in childrenoverweight status in children2)2) parents serve as powerful models of parents serve as powerful models of

eating and exercise behaviors for eating and exercise behaviors for their childrentheir children

3)3) parental involvement in treatment parental involvement in treatment for pediatric overweight is associated for pediatric overweight is associated with better outcomes for children with better outcomes for children

Parental Obesity and Child Parental Obesity and Child OverweightOverweight

Parental obesity is associated with overweight in children.Parental obesity is associated with overweight in children.

Children with 1 overweight parent have 3x risk of Children with 1 overweight parent have 3x risk of becoming obese themselves than do children of non-becoming obese themselves than do children of non-obese parents.obese parents.

Risk is higher for children with 2 obese parents.Risk is higher for children with 2 obese parents.

Children with obese parents are also less likely to Children with obese parents are also less likely to maintain weight lost during treatment. maintain weight lost during treatment.

Parents Are Role Models of Parents Are Role Models of Eating BehaviorEating Behavior

Parents’ direct modeling of fruit and vegetable Parents’ direct modeling of fruit and vegetable consumption is typically the strongest predictor of consumption is typically the strongest predictor of children’s own intake of these foods.children’s own intake of these foods.

Parents model eating attitudes, such as restraint and Parents model eating attitudes, such as restraint and disinhibition.disinhibition.

Parents can provide structure and predictable routines Parents can provide structure and predictable routines for eating, such as family meals.for eating, such as family meals.

Parents Model Exercise Parents Model Exercise BehaviorBehavior

Children whose parents exercise are more Children whose parents exercise are more likely to participate in physical activity.likely to participate in physical activity.

Parental support is one of the strongest Parental support is one of the strongest predictors of adolescents’ activity.predictors of adolescents’ activity.

Children of overweight parents are more Children of overweight parents are more likely than their peers to be sedentary, likely than their peers to be sedentary, and to prefer sedentary activities. and to prefer sedentary activities.

Parental Involvement in Tx is Parental Involvement in Tx is Associated with Better Child Associated with Better Child

OutcomesOutcomes Family-based tx is more successful than tx that Family-based tx is more successful than tx that

targets overweight child alone.targets overweight child alone.

Adolescents’ beliefs about their parent’s Adolescents’ beliefs about their parent’s willingness to make dietary changes are willingness to make dietary changes are associated with greater adolescent weight loss.associated with greater adolescent weight loss.

More intensive parental interventions are the More intensive parental interventions are the most likely to yield positive pediatric most likely to yield positive pediatric outcomes. outcomes.

Limitations of Previous Limitations of Previous ResearchResearch

Has targeted younger childrenHas targeted younger children

Who were not ethnically diverseWho were not ethnically diverse

Who were from intact familiesWho were from intact families

Who were not severely overweightWho were not severely overweight

Parent involvement usually limited to Parent involvement usually limited to parental weight loss program.parental weight loss program.

Specific Aims Implement and evaluate a randomized

parent intervention for its impact on main study outcomes of adolescent BMI and cardiorespiratory fitness.

Test the impact of the parent intervention on secondary study outcomes of adolescent dietary intake and psychosocial outcomes.

Specific Aims Identify predictors of adolescents’ success

in the intervention, including parental change, and examine potential gender and ethnic differences in outcomes.

Evaluate the impact of the parenting intervention on participants, including parental BMI change, parental physical activity levels, and parenting sense of competence.

Parent Intervention: Parent Intervention: HypothesesHypotheses

We hypothesize that adolescents whose We hypothesize that adolescents whose parents participate in the intervention will parents participate in the intervention will have:have:

1.1. greater decreases in BMIgreater decreases in BMI

2. greater increases in physical activity2. greater increases in physical activity

3. greater increases in cardiorespiratory 3. greater increases in cardiorespiratory health and fitness health and fitness

Why is it Important to Why is it Important to Target this Population?Target this Population?

African Americans at higher risk for African Americans at higher risk for obesity and its complications.obesity and its complications.

The older overweight children become, The older overweight children become, the more likely they are to be obese the more likely they are to be obese adults. adults.

Parents of older children may be more Parents of older children may be more motivated to help them lose weight.motivated to help them lose weight.

Schedule of Parent Schedule of Parent Assessment and Assessment and

InterventionIntervention Group Baseline

PretestParent Intervention

Post-Parent Group Test 6-month follow-up 12-month follow-up

Parenting Intervention

X X X X X

Parents of Adolescents in Standard Care Control Group

X X X X

InterventionIntervention

Sessions address:Sessions address: Parents as role models of eating and Parents as role models of eating and

exercise behavior exercise behavior Nutrition: Moderating Portion SizesNutrition: Moderating Portion Sizes Fruits and VegetablesFruits and Vegetables Family MealsFamily Meals Physical ActivityPhysical Activity

Session Topics Session Topics (continued)(continued)

The Feeding RelationshipThe Feeding Relationship Mindful Eating Mindful Eating Resisting Media Influences Resisting Media Influences Healthy Body Image and Dealing Healthy Body Image and Dealing

with Teasing with Teasing

SummarySummary Overweight and obesity is associated with Overweight and obesity is associated with

several health risks, including cancer.several health risks, including cancer.

Early intervention is key.Early intervention is key.

Our research aims to increase the Our research aims to increase the effectiveness of intervention with diverse, effectiveness of intervention with diverse, severely overweight adolescents by severely overweight adolescents by equipping parents to model healthy equipping parents to model healthy lifestyle behaviors.lifestyle behaviors.