School-based Obesity Prevention for Young Hispanic Children

Transcription

1 School-based Obesity Prevention for Young Hispanic Children A. Delamater, M. Villa, J. Hernandez, S. Rarback, A. Perry, A. Aftab, & J. Sanchez University of Miami

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3 Prevalence of Overweight and Obese year olds Non-H W Black Mex-Amer

4 Prevalence of Obesity in 2-19 year-olds Non-H W Black Mex-Amer

5 Prevalence of Overweight and Obese year olds Non-H W Black Mex-Amer

6 Prevalence of Obesity in 2-55 year olds Non-H W Black Mex-Amer

7 Prevalence of Overweight and Obese year olds Non-H W Black Mex-Amer

8 Prevalence of Obesity in 6-11 year olds Non-H W Black Mex-Amer

9 Prevalence of Overweight and Obesity year olds Non-H W Black Mex-Amer

10 Prevalence of Obesity in year olds Non-H W Black Mex-Amer

11 Reference Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM (2006). Prevalence of overweight and obesity in the United States, JAMA 295:

12 SES and Childhood Obesity Children living in poverty are 50% more likely to be overweight than children from non- poor families. From Delva et al. (2006).

13 Epidemiology of Pediatric Prevalence Obesity Prevalence: : about 18% of US youth are overweight; more than a third of all youth are at risk for overweight or overweight; rates are higher in minority children Incidence: : increased dramatically in the US over the past 20 years three times more overweight children today than 20 years ago Overweight more prevalent in lower income groups

14 Physical etiology in less than 5% of cases: endocrine dysfunction, hereditary disease, brain damage Genetic influences (Stunkard et al., 1986, 1990): MZ and DZ twins reared together vs. apart; adopted children and biological parents Etiology

15 Etiology Behavioral influences: Familial aggregation of diet (Patterson et al., 1988) and physical activity (Sallis( et al., 1988) Environmental influence: fast food Positive energy balance: : Caloric intake exceeds energy expenditure

16 Behaviors Associated with Child Obesity Eating out at fast food restaurants (Bowman et al., 2004) Consumption of sweetened beverages (James et al., 2004; Ludwig et al, 2001) Increased snacks and desserts (Jahns 2001) Jahns et al., Decreased F&V intake (Krebs-Smith et al., 1996) Increased TV (Viner & Cole, 2005)

17 Fast Food Consumption Bowman et al. (2004). Pediatrics, 113, Study of 6, yr-olds in US 30.3% consumed fast food on typical day Increased consumption related to male gender, being older, higher SES, being black, and living in South Children who ate fast food consumed for total energy, more fat, more added sugars, less milk, and fewer fruits and vegetables Consumption of fast food has an adverse effect on dietary quality so as to increase risk for obesity

18 Behavioral Differences Between Obese and Normal Weight Children Less physically active Watch more TV Eat more Eat faster with fewer bites Parents provide more food prompts

19 Average Daily Time Children Spent Watching Television, by Race/Ethnicity, :00 3:56 3:31 Hours:Minutes 3:00 2:00 1:00 2:22 0:00 White Black Hispanic N = 3,155 children, ages 2-18 (nationally representative); margin of error = +3-5% Source: Kaiser Family Foundation. Kids and Media at the New Millenium, 1999

20 Hours of TV on Typical Weekday for Infants and Toddlers Certain & Kahn (2002). Pediatrics, 109, mo mo mo Age of Child in Months 0 hours 1-2 hours 3 or more

21 Tractory of TV Viewing over Time as a Function of Maternal Education Mean Hours per Day Child Age in Years < 12 yrs all children 16 + yrs

22 TV Viewing Increased TV and decreased physical activity predicts higher BMI of children from to 6-76 years (Jago et al., Int J Obesity, 2005) In a study of 1,912 9 th graders, more TV viewing associated with greater intake of high-fat foods; African American teens reported more TV- viewing and high-fat food intake (Robinson & Kellen,, J Health Education, 1995) More TV viewing also associated with lowering of metabolic rate (Klesges 1993). Klesges et al., Health Psychology,

23 US High School Students Participation in Physical Activity: Youth Risk Behavior Survey, Sufficient No PA th 10th 11th 12th

24 Decline in Physical Activity in Black Girls during Adolescence Kim et al. (2002). NEJM, 347, Prospective study of 1213 black girls and 1166 while girls from ages of to years By years, 56% of black and 31% of white girls reported no habitual leisure time physical activity Lower levels of parental education and higher BMI associated with greater declines in activity Substantial declines in physical activity observed for girls during adolescence, particularly for black girls

25 35 Median Habitual Activity Scores by Age and Race MET- times/wk White Black 0 9 or or or or or or or 19 Age

26 Mexican American Children and Physical Activity Mexican American youth engage in less physical activity than white non-hispanic Hispanic youth (McKenzie et al., Developmental and Behavioral Pediatrics, 1992) Mexican American preschoolers spend less time outdoors and receive fewer parental prompts to be active (Sallis Health Psychology, 1993) Sallis et al.,

27 Parental Influences on Eating Stringent parental controls over children s s food intake can increase preferences for: High-fat, energy-dense foods Limit children s s acceptance of a variety of foods Disrupt children s s regulation of energy intake by altering responsiveness to internal cues of hunger and satiety (Birch & Fisher)

28 Appetite Regulation Young children are sensitive to internal cues of satiety Children s s learned lack of control of satiety may be significant factor in etiology of child obesity (Carnell & Wardle, 2007)

29 School Influences High-fat, high-sugar foods served in cafeterias Fast-food restaurants easily accessible Vending machines in hallways Physical education classes limited Potential for dietary and physical activity interventions

30 Prognosis More than 50% of children obese at age 7 will become obese adults More than 70% of obese adolescents remain obese as adults About 16% of normal weight adolescents become obese adults Parental obesity more than doubles the risk of children becoming obese adults: overweight yr-olds with at least one obese parent have 79% chance of being obese as adult Whitaker et al. (1997). NEJM, 337,

31 Public Health Significance The prevalence of overweight in children and the increasing incidence constitutes an epidemic Without effective treatment, it is clear that this condition continues into adulthood Adult obesity is associated with significant health complications, including cardiovascular disease and type 2 diabetes Impact of obesity on public health and the health care system is enormous

32 Phases of the Pediatric Obesity Epidemic Phase I increasing I average weight among children from all ethnic and SES groups Phase II emergence of serious weight- related health problems Phase III medical complications of obesity lead to life-threatening disease Phase IV acceleration of obesity rate through trans-generational mechanisms Ludwig, NEJM,, 2007

33 Phase III By 2035, prevalence of CHD will have increased from 5-16%, 5 16%, with more than 100,000 excess cases attributable to increased obesity among today s s youth Youth with type 2 diabetes will be at high risk for kidney failure and premature death Those with fatty liver will progress to hepatitis and cirrhosis Pediatric obesity may shorten life expectancy in US by 5 years within two decades, an effect equal to that of all cancers combined

34 Phase IV Trans-generational mechanisms: Obesity-promoting habits persist into adulthood Excess weight early in life may elicit irreversible biologic changes in hormonal pathways, fat cells, and the brain that increase hunger and adversely affect metabolism Adult obesity may increase risk of pediatric obesity through non-genetic mechanisms (perinatal programming) recent recent study showed maternal hyperglycemia during pregnancy predicted child BMI at age 7 (after adjustment for maternal weight gain and child birth weight)

35 What can be done to deal with this public health problem? Prevention of obesity through public health approach change change distribution of weight in the entire population of children Provide effective treatment for overweight and obese children However, few prevention programs have been shown to be effective and most overweight children do not receive services to help them control their weight

36 Ecological Model of Predictors of Overweight Fast food Community & Societal Characteristics Parent & Family Characteristics School lunches School Physical Education Nutrition Knowledge Types of foods in home Gender Dietary Intake Child Characteristics Child Weight Status Age Sedentary Activity Family TV viewing Parent Activity Patterns Work Hours Crime & Safety Parental Monitoring Genetics Physical Activity Feeding Practices Grocery Stores Perceptions Of Health Parent weight status Available Parks Davidson & Birch, 2001

37 School-based Health Promotion School sites, because of accessibility to the community, may be an optimal place for health promotion and weight control programs Reach 95% of Children Learning about Health 1-22 Meals per Day Link to Parents Teacher/Peer Reinforcement

38 School Health Promotion Research School interventions have targeted a variety of cardiovascular risk factors with health education curriculums and changes in food service and PE Somewhat positive effects in terms of reduced dietary fat intake, increasing F & V consumption, and increasing physical activity (eg,, Killen et al., 1988; Luepker et al., 1996, 1998; Perry et al., 1998) Weakest effects have been on BMI (Resnicow & Robinson, 1997)

39 Newer School Health Programs Emphasis on changing the school environment through social marketing Focus on prevention and reduction of overweight Planet Health added intervention components targeting reduced time spent with TV and video games girls girls showed lower BMI, and there was a relationship between reduced TV and lower weight (Gortmaker et al., 1999) Another study focused only on reduced TV viewing and found reductions in overweight (Robinson, 1999)

40 Reducing Children s s TV Viewing to Prevent Obesity Self-Monitoring of TV viewing and other sedentary behaviors TV Turnoff: No TV or video for 10 days 7-Hours per week budget More intelligent/selective viewing Electronic restriction on TV time (timer attached to power plug) Robinson, TN. JAMA, 1999, 282, 16:

41 Is School-based Health Promotion Intervention Effective? First generation results mixed some improvements on dietary intake and physical activity but not on weight Second generation somewhat more positive Reduced sedentary activity Improved weight control May need more intensive physical activity and more involvement from families to be more effective

42 Barriers to Implementation and Dissemination of School-based Obesity Prevention Crowded curriculum Low priority of health education Low priority of nutrition and PA relative to other social and health problems (eg( eg, HIV, violence, substance abuse) in health education Relatively weak intervention effects in prior studies

43 Prevention of Overweight in Children Will ultimately require systems change Public policy and legislation Changes in the built environment Changes in food industry marketing unhealthy food to children Change in school health policy (food services, PE, health curriculum) Social marketing

44 Community/Policy Change: Opportunities for Intervention Infrastructure Bike and Walking Paths Safe & Accessible Play Spaces, Parks Affordable/Free Recreational Programs and Facilities More Access to Fresh Fruit and Vegetables in Inner City Markets Policy Legislation Reduced Tax on Athletic Equipment Increased Tax on High-Fat Snack and Fast Foods Control Content/Frequency of Advertisements during Children s s TV Warning Labels on Fast Food and High Fat Snacks Limit Concentration of Fast Food Restaurants and Drive Thrus

45 Targets for Effective Obesity Prevention Increasing awareness of the obesity problem and motivating parents for health promotion Creating a culture of health with social marketing Increase physical activity and reduce sedentary behavior (TV) Increase consumption of fruits, vegetables, and whole grains Decrease consumption of sweetened beverages Reduce mindless snacking and fast food consumption Improved appetite regulation

46 Rationale for Current Study Hispanic children have increased risk for obesity Obesity increases risk for metabolic syndrome, type 2 diabetes, and cardiovascular disease To prevent metabolic syndrome, prevent obesity The school setting has opportunities for prevention of obesity and metabolic syndrome Provide program for young Hispanic children in grades K and 1 in school serving low-income families

47 Specific Aims 1) To conduct focus groups for refinement of a school-based multi-component intervention for health promotion of children in grades K-1 K 1 and pre-testing of the intervention materials.

48 Specific Aims 2) To test the feasibility and efficacy of the intervention by conducting a pilot study using a controlled randomized design. The hypothesis is that a school-based intervention will promote healthful dietary and physical activity behaviors, resulting in lower BMI and an improved metabolic risk profile, thereby reducing risk for metabolic syndrome. 3) To identify psychosocial variables that mediate or moderate health behavior change in children.

49 Methodology Formative research: focus groups with parents of Hispanic children in grades K-1, K and focus group with school administrators and K-1 K 1 teachers at one school Development of multi-component intervention Recruit low income Hispanic children in grades K-1 K 1 from two additional schools and conduct pilot study

50 Results of Focus Groups Parents: : want school to offer healthier foods at breakfast and lunch; want more physical activity for kids at school; want more nutrition education; want an integrated home-school program with parent events for practical health promotion School staff: : concerned about child obesity; believe that parents have primary responsibility to ensure children get good nutrition and physical activity; school health program would be helpful but cite barriers (focus on academics)

51 Pilot Study Randomize one school to control condition and the other to intervention Control: receive feedback from endocrinologist on cardio-metabolic risk of their children and also receive a packet of written health promotion materials Intervention: SPARK training for all K-1 K teachers; monthly health promotion newsletter and event for parents and kids held at school; work with food service staff; medical feedback Assessments at baseline, six months, and 12 months

52 Measures Anthropometrics: height, weight, BMI, waist circumference, body fat (by impedance) Cardio-metabolic risk: fasting blood glucose, insulin, and lipids; blood pressure Physical activity by accelerometry Dietary intake by 24-hour recall interviews with child and parent Parent measures: self efficacy and social support for healthy eating and physical activity

53 Baseline Results N=88 Hispanic children in grades K-1 K 1 recruited from two schools that are similar in demographics 43% exceed 85 th %ile for BMI, 28% exceed 95 th %ile for BMI 15% meet criteria for metabolic syndrome Among overweight children, 35% have low HDL, 38% have high triglycerides, 20% have insulin resistance, and 15% have high SBP

54 Designing and Implementing the Intervention Buy-in from principal Focus group (School Health Index) with representative school administrators, teachers, food service staff, PE staff, and parents Identify targets for obesity prevention Identify key staff people to coordinate activities (lead teachers for grades K and 1) Have a good program name: PAWS! Provide PAWS t-shirts t to kids attending events Have a motivated research staff

55 Intervention Components SPARK training for teachers to increase physical activity of children Consultation with food service staff to reinforce healthy food choices Building a vegetable garden Having vegetable class contests Outreach to parents: Monthly newsletters and school events Coordinate with PTA to improve food choices at school events (decrease donuts, cake, pizza, and sodas) Transform the school environment for health promotion (attention to visual environment)

56 Newsletters for Parents Increase awareness of the health problems of obesity Exposure to healthy lifestyle choices, including culturally appropriate recipes Tips for reducing screen time and increasing physical activity Advertisement for monthly events (garden and smoothie dance party, healthy snacking, fruit and veggie tasting, attention to internal cues of hunger and satiety)

57 Parental Mediators for Child Behavior Change Motivation for healthy lifestyle Self-efficacy efficacy for physical activity and dietary change Social support for physical activity and dietary change Will changes in these variables influence changes in children s s health behaviors?

58 Potential Moderators Parental stress and depression Family dysfunction Will high levels of these variables decrease the effect of intervention?

59 Process Measures Is the intervention being delivered as planned? % attendance at monthly family events Frequency of SPARK activities: by anonymous teacher self-report every two weeks, and by occasional unannounced direct observations Direct observation of food service staff Before and after photographs of school environment

60 Kindergarten Lunch Before After

61 Kindergarten Lunch Before After

62 Kindergarten Lunch Before After

63 Building the Kindergarten and 1st Grade Fruit and Vegetable Garden

64 Fruits and Vegetables From the Garden

65 Dance and Fruit Smoothie Party

66 Dance and Fruit Smoothie Party

67 Kindergarten Class Vegetable Chart

68 Teacher SPARK Training

69 1 st Graders participating in SPARK activities

70 Kindergarteners participating in SPARK activities

71 1 st Grade Cafeteria Kindergarten Cafeteria

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73 Conclusions A significant number of Hispanic children in grades K-1 K 1 are overweight and show evidence of cardio-metabolic risk There is a need for early intervention to prevent type 2 diabetes and cardiovascular disease in young Hispanic children Schools offer opportunities for prevention program and have been very responsive to this type of program Effective prevention will require change at many levels in the ecological model