Youth Obesity Causes, Youth Obesity Causes, Consequences, and SolutionsConsequences, and Solutions

Stephen Cook, MD, MPHStephen Cook, MD, MPHAssistant Professor, PediatricsAssistant Professor, Pediatrics

Golisano Children’s Hospital at StrongGolisano Children’s Hospital at Strong

Winter is almost over in Rochester; we Winter is almost over in Rochester; we can see the deer wandering around nowcan see the deer wandering around now

ConsequencesConsequences

The Metabolic Syndrome:The Metabolic Syndrome:Historical PerspectiveHistorical Perspective

Reaven G. Diabetes. 1988;37:1565-1607.

InsulinInsulinResistanceResistance

InsulinInsulinResistanceResistance

GlucoseGlucoseIntoleranceIntolerance

GlucoseGlucoseIntoleranceIntolerance HyperinsulinemiaHyperinsulinemiaHyperinsulinemiaHyperinsulinemia TGTG TGTG HDL-C HDL-C HypertensionHypertension

1988: Syndrome X1988: Syndrome X

CORONARY HEART DISEASECORONARY HEART DISEASECORONARY HEART DISEASECORONARY HEART DISEASE

Criteria for Metabolic Syndrome inCriteria for Metabolic Syndrome inAdults and AdolescentsAdults and Adolescents

Rates of Metabolic Syndrome by Increased Rates of Metabolic Syndrome by Increased Smoke Exposure in US teensSmoke Exposure in US teens

DyslipidemiaElevated BPAbnormal glucose-insulin metabolism

Pro-inflammatory factorsPro-thrombotic factors

Diabetes

Cardiovascular Disease

Obesity

Abdominal Obesity

Genetics, Peri-natal, Puberty, Diet, Physical Activity

Tobacco use/exposure

Potential Precursors:

AdiponectinOther inflammatory

cytokines

Bold = factors included in this study

Proposed Metabolic Syndrome Factors in the Life Proposed Metabolic Syndrome Factors in the Life Course from Obesity to Cardiovascular DiseaseCourse from Obesity to Cardiovascular Disease

Co-morbidities with Cardio-metabolic Risk among youth

Non Alcoholic Fatty Liver DiseaseNon Alcoholic Fatty Liver Disease

Polycystic Ovarian SyndromePolycystic Ovarian Syndrome

Obstructive Sleep ApneaObstructive Sleep Apnea

Polycystic Ovarian Syndrome

Menstrual Irregularities / InfertilityMenstrual Irregularities / Infertility

Small Cysts on OvariesSmall Cysts on Ovaries

Hyper-AndrogenismHyper-Androgenism

Insulin ResistanceInsulin Resistance

+/- obesity+/- obesity

Increased CVD riskIncreased CVD risk

Prevalence of Metabolic Syndrome and Prevalence of Metabolic Syndrome and Components among Obese Teen GirlsComponents among Obese Teen Girls

Rossi, et al. Journ of Clin Endo & Met 2008; 93:4780

Kotronen, A. et al. Arterioscler Thromb Vasc Biol 2008;28:27-38

A schematic representation of how components of the metabolic syndrome relate to fat accumulation in the liver

Cardiovascular Risk Factor Values by Liver Cardiovascular Risk Factor Values by Liver Status in Obese Children & AdolescentsStatus in Obese Children & Adolescents

Schwimmer, J. B. et al. Circulation 2008;118:277-283

Schwimmer, J. B. et al. Circulation 2008;118:277-283

Distribution of features of metabolic syndrome in obese youth with and without NAFLD

Solutions?Solutions?

Greater Rochester Health Foundation Greater Rochester Health Foundation Strategic Areas of FocusStrategic Areas of Focus

Neighborhood Health Status ImprovementNeighborhood Health Status Improvement

Health system improvementHealth system improvement

Prevention Prevention

GRHF Childhood StrategyGRHF Childhood Strategy

GOAL: Reduce the prevalence of overweight and obesity from 15% to 5% of Monroe County children

ages 2-10 by 2017

[from 12,144 kids to 4,081 kids]

Advance policy and practice solutions

Execute a community

communications campaign

Increase physical activity and improve

nutrition

Engage the clinical

community

Change is hardChange is hard

Most difficult steps: Most difficult steps:

– Increasing my own physical activity Increasing my own physical activity is difficult (68% moderate to very is difficult (68% moderate to very difficult)difficult)

– Reducing TV time for my children is Reducing TV time for my children is a challenge (63%)a challenge (63%)

– Getting my kids to eat healthier Getting my kids to eat healthier won’t be easy (61%)won’t be easy (61%)

OpportunitiesOpportunities

Getting my kids to be physically Getting my kids to be physically active is doable (70% Easy)active is doable (70% Easy)

I want my child’s school to offer I want my child’s school to offer more physical activity (84% Very more physical activity (84% Very Important)Important)

I trust health and nutrition I trust health and nutrition information from my doctor (63% information from my doctor (63% Trust a Lot), and pharmacist Trust a Lot), and pharmacist (37%), more than my family (20%) (37%), more than my family (20%) and the Internet (12%)and the Internet (12%)

I am willing to engage in physical I am willing to engage in physical activity to lead my children to be activity to lead my children to be more active (56% Easy)more active (56% Easy)

TownTown Normal / Normal / UnderweightUnderweight OverweightOverweight ObeseObese

RochesterRochester 60.6%60.6% 16.7%16.7% 22.7%22.7%

HamlinHamlin 62.3%62.3% 16.9%16.9% 20.8%20.8%

IrondequoitIrondequoit 63.9%63.9% 19.3%19.3% 16.8%16.8%

GatesGates 64.7%64.7% 15.2%15.2% 20.1%20.1%

ClarksonClarkson 64.8%64.8% 22.8%22.8% 12.3%12.3%

GreeceGreece 70.3%70.3% 16.4%16.4% 13.4%13.4%

SwedenSweden 70.6%70.6% 14.6%14.6% 14.8%14.8%

ChiliChili 72.1%72.1% 13.8%13.8% 14.1%14.1%

HenriettaHenrietta 72.5%72.5% 17.1%17.1% 10.4%10.4%

East RochesterEast Rochester 73.5%73.5% 8.7%8.7% 17.9%17.9%

RigaRiga 74.7%74.7% 12.8%12.8% 12.5%12.5%

WebsterWebster 74.7%74.7% 14.4%14.4% 10.9%10.9%

PerintonPerinton 74.8%74.8% 13.5%13.5% 11.8%11.8%

PenfieldPenfield 76.7%76.7% 13.0%13.0% 10.4%10.4%

OgdenOgden 76.9%76.9% 14.9%14.9% 8.2%8.2%

ParmaParma 77.5%77.5% 7.7%7.7% 14.8%14.8%

WheatlandWheatland 78.7%78.7% 8.0%8.0% 13.4%13.4%

BrightonBrighton 78.8%78.8% 13.8%13.8% 7.4%7.4%

PittsfordPittsford 80.3%80.3% 11.5%11.5% 8.2%8.2%

MendonMendon 83.7%83.7% 9.3%9.3% 7.0%7.0%

RushRush 83.8%83.8% 12.9%12.9% 3.4%3.4%

TotalTotal 69.9%69.9% 14.9%14.9% 15.1%15.1%

BMI categories for children living in BMI categories for children living in Rochester, by Race/EthnicityRochester, by Race/Ethnicity

   BMI CategoryBMI Category

RaceRaceNormal / Normal / Under Under WeightWeight

Over Over weightweight ObeseObese

African-African-AmericanAmerican 61.8%61.8% 18.0%18.0% 20.2%20.2%

HispanicHispanic 53.4%53.4% 19.8%19.8% 26.8%26.8%

CaucasianCaucasian 62.3%62.3% 16.3%16.3% 21.4%21.4%

OverallOverall 59.9%59.9% 18.2%18.2% 21.9%21.9%

Funded activities forFunded activities fornext 3 yearsnext 3 years

Early childhood - $1.8 millionEarly childhood - $1.8 million

Clinical outreach - $750,000Clinical outreach - $750,000

Advocacy - $467,000Advocacy - $467,000

Suburban School projects - $820,000Suburban School projects - $820,000

Community Champions - $500-1000/eaCommunity Champions - $500-1000/ea

Media/Social Marketing CampaignMedia/Social Marketing Campaign– ~ $5 million over 3 years~ $5 million over 3 years

Greater Rochester Healthy Greater Rochester Healthy Child Care 2010:Child Care 2010:An early childhood overweight An early childhood overweight and obesity prevention programand obesity prevention program

The Children’s InstituteThe Children’s Institute

Eat Well / Play Hard EnhancedEat Well / Play Hard Enhanced– Child Care Council & CentersChild Care Council & Centers

Hip Hop to Health JrHip Hop to Health Jr– Rochester Childfirst Network & Home care providersRochester Childfirst Network & Home care providers

9 sites in each arm, 3 arms per year9 sites in each arm, 3 arms per year

3 years3 years

Interactive, group training that promotes collaborative learning, implementing small cycles of changes, with practice feedback and sharing lessons learned from other teams

Clinical Strategy:

Greater Rochester Obesity Collaborative

Institute for Healthcare Improvement Break Through Series (BTS) Model

Use a Learning Collaborative approach to train pediatric primary care providers

Collaborate with Expert Consultants from NICHQ and AAP

Recruit motivated practice teams: physician, nurse, off mgr & PARENTPARENT

Adapt AMA/CDC Expert Recommendations for local community

Conduct 4 training workshops with follow-up conference calls and

individual practice visits over ~ 12 months, conduct 3 cycles over 3

years

Provide on-line/free access simple practice tools and link to local

resources

Create a Community-wide toolkit and Region-specific resource guide

G-ROC

Was BMI Plotted?

76%

22%

3%

95% 95% 95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Yes No Missing

Perc

en

tag

e

All Charts

Goal

Was Weight Status Discussed with the Family?

42%37%

21%

95% 95% 95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Yes No Missing

Perc

en

tag

e

All Charts

Goal

Did Provider Counsel on Nutrition and Physical Activity?

27%

1%

39%

20%13%

95% 95% 95% 95% 95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nutrition PhysicalActivity

Both Neither Missing

Perc

en

tag

e

All Charts

Goal

G-ROC

Practice and Overall results

For October 2008

Was BMI Plotted?

100%

0% 0%

94%

3% 3%

95% 95% 95%

0%

20%

40%

60%

80%

100%

120%

Yes No Missing

Perc

en

tag

e Genesis n = 17

Overall Resultsn = 135

Goal

Policy ProjectPolicy Project

HEALTHI Kids:HEALTHI Kids:Healthy Eating and Active Living Healthy Eating and Active Living

THrough policy and practice THrough policy and practice Initiatives for KidsInitiatives for Kids

45

Finger Lakes Health Systems Agency

Wade S. Norwood Director of Community Engagement

(585) 461-3520 ext.110wadenorwood@flhsa.org

Convening HEALTHi KidsConvening HEALTHi Kids

•Texas Obesity Policy Portfolio 2006, Texas Department of State Health Services, Center for Policy & Innovation

• Convene 27-member HEALTHi Kids Policy Team

•Examine public policy/practices that promote youth’s healthy eating and active living.

Eliminate the availability of food in schools that compete with the national school breakfast and lunch program. Mandate the development and execution of nutritional

standards so all food available on school campuses is consistent with a set of community standards.

Mandate the development and execution of nutritional standards for preschools, childcare centers, and school-age childcare programs, so that food and drinks

available comply with Dietary Guidelines for Americans or equivalent community standards.

Create policies that are supportive of breastfeeding throughout the community and all hospitals in Monroe County meet the

WHO Baby Friendly Hospital Criteria (Ten Steps to Successful Breastfeeding for Hospitals).

Improve the safety of, the perception of safety of, and access to recreational facilities, bike trails, parks, and green spaces, while expanding after-hour

access to schools and promoting safe play.

Require that K-12 grade students are provided with 45-minutes of moderate to intense physical activity daily.

QuestionsQuestions

My Drive HomeMy Drive Home

Monroe County Obesity Rate Monroe County Obesity Rate by Geography, 11 – 14 yr olds, 1999by Geography, 11 – 14 yr olds, 1999

14.3

23.1

0

5

10

15

20

25

30

City Suburbs

% OBESE16%16%