Progress and Updates on the War Against Childhood Obesity

Transcription

1 Progress and Updates on the War Against Childhood Obesity Elizabeth S. Kuhl, PhD Assistant Professor of Pediatrics Pediatric Prevention Research Center Wayne State University School of Medicine 1

2 Objectives Prevalence and correlates of obesity in early childhood Obesity prevention and intervention: conception to the preschool years Changing the environment to support health WIC s important role in the war on childhood obesity 2

3 Prevalence of Childhood Obesity 25 Percent of Children years old 6-11 years-old years-old NHANES Iteration Weight Status: Preschoolers 12 Percent NHANES Iteration More obese 97 th >percentile Less obese th percentile 3

4 Ethnic/Racial Disparities: Preschoolers 20 Percent Non- Hispanic White Non- Hispanic Black Hispanic NHANES Iteration Income Disparities: Preschoolers Percent NHANES/PNSS National All low-income Michigan lowincome 4

5 Physical Health Consequences Risk-factors of cardiovascular disease Asthma Run/walk difficulties Headaches (Gopinath et al., 2011; Skinner et al., 2010; Williams et al., 2004) Psychosocial Consequences More behavior problems More peer-relationship problems Lower health-related quality of life (Cramer et al., 1998; Datar et al ; Kuhl et al., 2012; Marguiles et al., 2008) 5

6 Weight-Based Stigmatization Starts as early as age 3 By age 4, children attribute stigma to weight Overweight characters in children s movies and cartoons have more undesirable traits Negativity and stigma associated with TV use (Herbozo et al., 2004; Klein et al., 2005; Puhl et al., 2013) Weight-Based Stigmatization Bullying Higher rates than non-overweight peers Teachers view as most problematic type Teasing Received from peers, teachers, and parents Overweight children are perpetrators and victims In-group stigmatization (Olivera et al., 2013; Puhl et al., 2013) 6

7 Consequences of Stigma Emotional Depression, anxiety, low self-esteem Body dissatisfaction Social Isolation Less likely to be nominated as friends Academic Negative impact on grades Avoid school More disordered eating (Herbozo et al., 2004; Klein et al., 2005; Puhl et al., 2013) Obesity Persists Across Development Infants and todders Excess weight gain by 6 months predicts obesity at age times more likely to be overweight ages 1-4 Preschoolers 4-6 times more likely to be overweight at age % of severely obese children became obese adults 9.7% of preschoolers have BMI>97 th percentile (Cunningham et al., 2014;Dennison et al., 2006; Nadar et al., 2006; Taveras et al., 2009) 7

8 Correlates of Obesity in Early Childhood Healthy Weight 8

9 Obesity Infancy High birth weight Rapid weight gain Breastfeeding Timing of complementary food introduction (DuBois et al., 2006; Davis et al., 2012; Hawkins et al., 2009) 9

10 Temperament Traits associated with obesity Poor self-regulation/effortful control High emotionality Low/High negative affectivity High and low soothability Obesity promoting eating behaviors Food fussiness Enjoyment of food Eating in the absence of hunger Tantrums over food Increased infant TV use (Anzman-Frasca et al., 2014; Bergmeier et al., 2014; Leung et al., 2014; Thompson et al. 2013) Feeding Practices Restriction Pressuring to Eat Rewarding with Food Feeding Feeding Styles Indulgent Permissive Non-Responsive (Ventura & Birch, 2008; Hurley et al., 2011) 10

11 Infants Sleep 2 x more likely to be overweight at age 3 if <12 hours/day Preschoolers 1-2 x more likely to be obese if <10 hours/day In obese, each extra hour sleep 0.14 lower BMI z-score 186 fewer calories/day (Clifford et al., 2012; Locard et al.,, 1992; Sekine et al., 2002; Taveras et al., 2008; von Kries et al.2002;) Neurocognitive Relative reinforcing value of food Associated with excess weight gain in children Higher BMI z-score in preschoolers Reward sensitivity Associated with BMI Self-control/regulation Predicts overweight at age 5, BMI at age 30 Greater weight gains over 9 years Eating in the absence of hunger May be food specific Influenced by availability (Francis et al. 2012; Graziano et al. 2010; Pieper et al. 2013; Sobhany et al. 1985; Rollins et al., 2014) 11

12 Marshmallow Test Prevention and Intervention to Address Early Childhood Obesity 12

13 Pregnancy Fit For Delivery All continue with standard of care Intervention 1 in-person, weekly post-cards, 3 phone calls Goal setting, self-monitoring Weight graphs and feedback at standard care visits Bi-monthly calls & structured meal plan if over/under weight gain recommendations Outcomes Normal weight women less likely to exceed IOM guidelines 2 x more likely to achieve pre-pregnancy weight < 6 months irrespective of weight status Significantly lower weight retention at 12 months (Phelan et al. 2011; 2014) 13

14 TOPS Study Only pregnant women who were obese All receive diet consult and calorie goal in addition to standard of care Intervention groups: Physical activity (PA): step goal + pedometer PA + Diet: step goal, pedometer, bi-weekly diet related follow-up Outcomes Less weight gain for PA and PA+Diet More participants in PA and PA+Diet meet IOM guidelines (Renault et al. 2014) Summary Risk-Factor Excess gestational weight gain Behavior Change Strategy Goal setting Self-monitoring Frequent contact 14

15 Infants Soothe and Solids Home-based sessions delivered by a nurse Breastfeeding support provided to all Interventions Soothe & Sleep (2-3 weeks after birth; 1 session) Solids (4-6 months after birth; 1 session) (Paul et al., 2012) 15

16 Soothe and Solids Both interventions vs. 1 or no intervention: Lower weight-for-height percentile Slower rate of weight gain Breastfed & Soothe/Sleep vs. no intervention More sleep Fewer feeds (including nocturnal) Solids vs. no intervention Fewer moms introduce solids before 4 months Acceptance of vegetable puree (Paul et al., 2012) Healthy Beginnings Home-based sessions led by nurses 1 session prior to birth, 7 sessions after birth Intervention targets Breastfeeding No solids until 6 months Healthy diet and activity levels Outcomes at age 2 Significantly lower BMI Fewer were overweight or obese Parents less likely to use food as a reward Less likely to have meals in front of TV/TV on at dinner (Wen et al., 2012) 16

17 Summary Risk Factor Non-responsive feeding Behavior Change Strategy Infant cry cue discrimination Child satiety signs Feeding to soothe Non-feeding soothing strategies (e.g., swaddle, rocking, check diaper first) Short sleep Solid food introduction before 4 months Distinguish cues for night vs. day Increasing length between night feeds Self-monitoring Education No cereal in bottle Developmental signs of readiness Summary Risk Factor Food refusal Food as a reward No TV during meals Behavior Change Strategy Structured exposure task Non-food soothing strategies Non-food rewards Engage with child Attend to positive eating behaviors 17

18 Preschoolers Healthy Habits, Happy Homes 6-month intervention Motivational coaching by health educator Education materials in the mail Text messages Intervention targets Eating meals as a family Adequate sleep Limiting screen time Parenting skills Outcomes Significant decrease in BMI and weekend TV use Significant increase in sleep (Hains et al., 2013) 18

19 6-month intervention LAUNCH Alternating group sessions and individual home visits Intervention targets Preschooler and parent weight control Diet and activity Parenting skills Home food and activity environment (Boles et al., 2010; Stark et al., 2011) Preschooler Weight Status 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline 6 months 12 months Overweight Obese Severely Obese 19

20 Parent Weight Status 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline 6 months 12 months Healthy Weight Overweight Obese Caloric Intake Calories ESC LAUNCH Time x Group Interaction Effect: F(2, 50)=6.61, p=.01 20

21 Television Use Minutes ESC LAUNCH Moderate/Vigorous Activity 100 Minutes ESC LAUNCH 21

22 Summary Risk-factor Short sleep Inconsistent, non-family meals Behavior Change Strategy Bedtime routine clock No TV in bedroom Read books Eat dinner as a family 2 > hours television daily Fitness dice Activity ring New uses for old stuff Self-monitoring Food refusal Differential attention Exposure Shaping Risk-factor Tantrums Summary Behavior Change Strategy Differential attention If/then statements Time Out Stimulus control Decrease unhealthy foods Increase healthy foods Stimulus control Served in moderation Appropriate portion sizes Non-Food Rewards Self-monitoring Choices Kids decide when finished Shape instead of pressure Self-monitoring 22

23 Summary Risk-factor Over consumption of energydense foods and beverages Under-consumption of nutrientdense foods and beverages Behavior change strategy Stimulus control Served in moderation Appropriate portion sizes Non-Food Rewards Choices Kids decide when finished Shape instead of pressure Changing the Environment to Promote Healthy Choices 23

24 Parent, Family Characteristics Child Characteristics Child Weight Environment, Community, Societal Characteristics Parent, Family Characteristics Child Characteristics Child Weight 24

25 Food Marketing to Children 1.6 billion spent on food marketing to children Nearly 50% for TV ads Children s Food & Beverage Advertising Initiative Target marketing to children <12 years-old 5 companies and corporations Products in ads must meet nutritional standards 13 companies and corporations Does not apply to in-store promotions or packages Changes in Ads Viewed % Change Yogurt +52% Other Dairy +63% Fruits +55% Vegetables +55% Cereal -14% Sweet Snacks -31% Candy +65% Juice, fruit drinks, sports drinks +38% Carbonated drinks +14% Restaurants & Fast Food +20% (Harris et al., 2013) 25

26 Changes in Ads Viewed % Change Yogurt +52% Other Dairy +63% Fruits +55% Vegetables +55% Cereal -14% Sweet Snacks -31% Candy +65% Juice, fruit drinks, sports drinks +38% Carbonated drinks +14% Restaurants & Fast Food +20% (Harris et al., 2013) Licensed Characters Adding character stickers to packaging Greater preference, even if same taste as no sticker Taste better than same food without sticker Results in eating more fruits and vegetables Effects maintained even if stickers removed Increases selection and purchase of healthy food choices Kids pick apple with Elmo sticker over cookie with no sticker Parents purchase more vegetables when packaging includes a licensed character (Gunnardottir et al., 2010; Keller et al., 2012; Radice, 2007; Roberto et al., 2010; Wansink et al., 2012) 26

27 Licensed Characters-Changes McDonalds happy meal box without characters or games Disney end its contract with McDonalds Sesame Street permits free use of characters on produce items Price 27

28 Is a healthy diet more expensive? Whole food vs. convenience food diet Cost per calorie to meet USDA food group guidelines lean meat > grains > veg > milk/dairy > fruit Proportion of annual income 18% for whole food diet 38% for convenience food diet Monthly Costs 1 year-old 2-3 years-old Adults Milk/dairy $55.08 $55.08 $82.67 Lean meat/beans $9.17 $12.25 $30.57 Fruit $18.75 $18.75 $28.15 Vegetables $19.33 $25.83 $64.56 Grains $7.17 $10.75 $21.54 Total-whole food $ $ $

29 Monthly Costs 1 year-old 2-3 years-old Adults Milk/dairy $55.08 $55.08 $82.67 Half the cost to eat healthy! Lean meat/beans $9.17 $12.25 $30.57 Fruit $18.75 $18.75 $28.15 Vegetables $19.33 $25.83 $64.56 Grains $7.17 $10.75 $21.54 Total-whole food $ $ $ Total-convenience $ $ $ Price Elasticity How food demand changes as cost changes Cross-price: substitutions due to price manipulation If increase cost of unhealthy food items Increased purchase of healthy food items Decreased purchase of unhealthy food items If decrease cost of healthy foods Increased purchase of healthy foods Increased purchase of unhealthy foods (Epstein et al. 2012) 29

30 Price Elasticity Subsidies and discounts Purchase more nutrient-dense foods when price decreased Purchase and consume more fruit/veg with vouchers Price effects are large than supplementing with information (Epstein et al. 2012) WIC s Role in the War Against Childhood Obesity 30

31 Healthy Food Access and Availability WIC Food Package Changes Includes fruit, vegetables, and whole grain products 1% and skim milk only for children ages 2-4 Decrease in juice quantity All juice=100% fruit juice 31

32 Changes in Healthy Food Availability More WIC-certified stores Greater changes in product availability than non-wic-certified stores Especially in low-income neighborhoods Food group changes Whole grains > dairy > fruit and vegetables (Andreyeva et al; Hillier et al., 2012; Zenk et al., 2012) Changes in Food Purchases Whole grains Tripling of whole wheat bread with WIC vouchers Increase in brown rice and whole-grain tortillas No change in non-wic grain purchases Dairy 50% decrease in whole milk using WIC vouchers 72% increase lower-fat milks using WIC vouchers No change non-wic milk purchases Juice 24% decrease using WIC vouchers No change in non-wic juice purchases (Andreyeva et al., 2013a, b; 2014) 32

33 Changes in Dietary Intake Whole grains Significant increase Dairy Significant increase in low-fat/no-fat dairy Significant decrease in whole-fat dairy Fruits and vegetables Mixed evidence for vegetables Significant increases in fruit 2.7% decrease in obesity for preschoolers in NYC Associations between changes for moms and kids (Chiasson et al., 2013; Odoms- Young; Whaley et al 2012) Breastfeeding 33

34 Changes to WIC Food Package Larger food package for exclusive breastfeeding Double amount of infant fruits/vegetables Only group that receives infant meats Moms receive more milk, cheese, eggs, fruit, and vegetables up to child age 12 months Partial breastfeeding Food package to 12 months Some formula No breastfeeding Food package only to 6 months Formula Changes in Breastfeeding Rates Mixed findings on breastfeeding initiation More women receive fully compared to partial breastfeeding packages Increase in-hospital breastfeeding leads to increased breastfeeding during infancy Increase in exclusive breastfeeding (Langellier et al., 2014; Whaley et al., 2012; Wilde et al., 2012) 34

35 Fit WIC Program 5 states funded to examine strategies for improving obesity prevention efforts within WIC program Emphasis on families AND staff Outcomes Increased physical activities, use of community activity centers, and drinking water by families Increased healthy lifestyle behaviors for staff Increased confidence in counseling on overweight Video on barriers and solutions to childhood obesity (training) ( cworks/sharing_center/gall ery/healthytogether.html; Herrara et al., 2013) 35

36 ( ( Herrara et al., 2013) 36

37 Partnerships to Improve Obesity Care and Program Access in Michigan Partnership Michigan WIC Program Michigan State University Moms in Motion Pilot study completed, larger trial under way Both NIH funded Developed for WIC moms by WIC moms For oveweight/obese moms enrolled in WIC who are at least 6-months postpartum (Chang et al., 2010; Chang et al., 2014) 37

38 Moms in Motion Both groups continue with WIC care as usual Intervention-10 weeks Alternate weeks for DVD vs. teleconference Complete action plan and self-monitor 1-2 goals for 7 days after each DVD (Chang et al., 2010; Chang et al., 2014) Moms in Motion Compliance with intervention protocol Mean of 3.2 of 5 chapters viewed Mean of 2.17 of 5 teleconferences attended Intervention trends 2 and 8 months post-treatment Decreases in weight, blood glucose, stress, negative feelings Increases in positive feelings, physical activity No change in fat, fruits, and vegetables (Chang et al., 2010; Chang et al., 2014) 38

39 A partnership between the Michigan WIC Program and Wayne State University R21-HD NIH/NICHD Project Grow Strong Developed for WIC families by WIC families Recruit from 2 Detroit-based WIC clinics Northeast North End Inclusion Preschooler age 2-4 years-old with BMI>85 th Caregiver 18> years-old with BMI>25 39

40 Project Grow Strong All families continue with WIC care Standard of care 24 families monitor preschooler growth for 7 months Intervention 48 families 4 months, 14 sessions Sessions at WIC, family s homes, and food market Targets Intervention Preschooler and caregiver weight control Diet and activity changes Child behavior management and feeding skills Behavioral weight loss strategies Innovation First WIC-Academic partnership to develop a preschool obesity intervention Led by community health worker Experiential learning Life skills to address SES challenges Dietary Exchange System 40

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42 Summary Prevalence of early childhood obesity is down, but disparities persist Novel targets provide new directions for enhancing childhood obesity prevention and intervention programs Emerging literature demonstrating efficacious and sustainable programs for address obesity from conception to the preschool years Summary Ongoing efforts to modify policies so health is the environmental default WIC is a leader in the war against childhood obesity, especially in Michigan! 42

43 Questions? 43