Transcript Document

Obesity Prevention and Education for
School Nurses
The planning committee &
faculty attest that no relevant
financial, professional or
personal conflict of interest
exists, nor was sponsorship of
commercial support obtained,
in the preparation or
presentation of this educational
activity.
Objectives
• Define obesity and relate current trends in Arkansas and in
the US.
• Discuss risk factors for childhood obesity.
• Explain health consequences of obesity.
• Describe importance of health assessment especially blood
pressure monitoring in regards to childhood obesity.
• Explain the relationship between Acanthosis nigricans and
obesity.
• Describe the process for appropriate height and weight
measurement for children.
• Review pertinent legislation.
• List resources available for schools and school nurses to
combat childhood obesity.
Obesity Trends
Definition of Obesity
Obesity is defined as an increased body
weight in relation to height, when
compared to some standard of
acceptable or desirable weight.
Obesity / Overweight in Children
• Obesity in children / youth refers to
age and gender- specific BMI that is
equal to or greater than the 95th
percentile of the CDC BMI charts
• Overweight/at risk for obesity
between 85th – 94th percentile
(IOM, 2007)
In the Past Three Decades…
Number of overweight:
• 6-11 year olds tripled
• Adolescents tripled (Gerberding & Marks, 2004)
• Overweight adults tripled (>60%)
Obesity in Children
16.3% of children and adolescents ages 2 -19 years are
obese
• 11% considered extremely obese
• 12.4%
2 - 5 year old
• 17.4%
6-11 year olds
• 17.6%
12-19 year olds
31.9% are overweight / obese
(Ogden, JAMA, 2008)
Obesity in the United States
http://www.cdc.gov/obesity/data/trends.html
2009
Trends in Obesity Among Boys
Trends on Obesity Among Girls
The Epidemic of Childhood
Overweight and Obesity
•  9 million children >6 yrs obese (IOM, 2005)
•  25 million children / adolescents are obese or
overweight (NHANES, 2007)
»Males 18.2%
»Females 16.0 %
• HHS estimates that 20% of children / youth in the
US will be obese by 2010.
(GAO-07-260R Childhood Obesity and Physical Activity)
http://www.gao.gov/new.items/d07260r.pdf
Risk Factors for Obesity
Risk Factors for Obesity:
 Diet
 Inactivity
– Sedentary kids
more likely to
gain weight
– High-fat foods dense
in calories
– Inactive leisure
– Soft drinks, candy,
activities
desserts high in sugar
/ calories
– High-calorie foods
Risk Factors for Obesity:
 Genetics
• Overweight family and child may be
genetically predisposed to gain excess
weight
• environment of high-calorie foods
• physical activity may not be encouraged
Heredity… / Genes
•  80%
of children with two overweight
parents will become overweight
•  40%
of children with one overweight parent
will become overweight
•  7–9%
of children with no overweight parents
will become overweight
http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.htm
Percentage of Overweight Children and
Youth Who Become Overweight Adults
80
70
60
50
Preschool
School-age
Adolescent
40
30
20
10
0
Percentage
(National Institute for Health Care Management, Nov 2003)
Risk Factors for Obesity:
 Psychological
• Some eat to cope with problems or deal
with emotions; stress or boredom
– Parents may have similar tendencies
Environmental / Media
Temptation at Every Turn
• Chips, cookies, and other less healthy
food choices are marketed to children
via media.
Behavioral/Socio-cultural
•
•
•
•
Sedentary lifestyles 
Calorie-dense foods 
Large portion sizes 
Excessive television viewing / video
games  low energy expenditure
• Parent modeling - eating and exercise
behaviors
Consequences of Obesity
Health Consequences: Adult
Premature Death
• 500,000 deaths per year –
surpassing tobacco
• Risk increases with
increased weight
(USDHHS, 2001)
Health Consequence: Children
Risk of CVD
• Hypertension
• Elevated insulin levels
• Dyslipidemia
– Elevated low density
lipoprotein (LDL)
– Abnormal triglyceride levels
Other Health Consequences Children
• Sleep apnea
• Asthma
• Risk for Kidney
problems
• Gastrointestinal
– fatty liver disease
– elevated liver
enzymes
– gallstones and
cholecystitis
– gastroesophageal
reflux
– constipation
Other Health Consequences Children
• Endocrine disorders
– T2DM
– Polycystic Ovary
Syndrome
– Early sexual
maturation
• Orthopedic disorders
• Skin conditions
• AN – seen in:
 10% of obese
white children
 50% of obese
black children
• Skin fungal
infections
Health Consequences: Psychosocial !!!
Children
• Depression/Anxiety
• Quality of Life
• Negative self-esteem/Poor body image
• Feelings of chronic rejection / Withdrawal from
interaction with peers/Behavioral problems
• Decreased endurance / involvement
• Social, academic and job discrimination (Deckelbaum and
Williams, 2001)
Health Consequences for
Children – Risk of T2DM
• Clearly, the growth in the treatment of type 2
diabetes could signal the beginning of a multitude of
long-term healthcare needs for many of these
children.
Economic Burden of Obesity
The Economic Estimates of the impact of obesity are
astronomical:
• 1995 - Approximately $52 billion was
attributed to obesity
• 2003 - This figure had increased to $75 billion
(CDC, J. Gerberling, 2005)
According to one estimate total health care spending
for children who receive a diagnosis of obesity is
approximately $750 million a year
http://www.medstat.com/pdfs/childhood_obesity.pdf
Economic Burden of Obesity
• Obesity is the No. 1 driver of increasing
health care costs in the US today
• Diabetes contributes to health care
disparities in the United States
Recap: Rising obesity rates - result of a
number of trends in the US
• Americans consume 300
• Parks & recreation spaces
more calories/ day than they are not considered safe or
did 25 years ago & eat less
well maintained in many
nutritious foods
communities
• Nutritious foods are…more • Many school lunches do
expensive than calorienot meet nutrition
dense, less nutritious foods
standards -children engage
in less physical activity in
• Americans walk less / drive
school
more -- even for trips of less
than one mile
• ↑ screen time (TV, video
games) contributes to ↓
• Adults often work longer
activity…for children
hours & commute farther
Assessing the Overweight/Obese Child
Assessment of the Overweight and
Obese Child and Adolescent
•
•
•
•
•
Hypertension
Acanthosis Nigricans
Nutrition and Physical Activity
Child and Family History
Height/Weight/BMI
Definition of Hypertension
Average Systolic blood pressure (SBP)
[higher number] and/or diastolic blood
pressure (DBP) [lower number] that is ≥ to
the 95th percentile for gender, age and
height on 3 or more occasions
Definition of Pre-Hypertension
Average SBP or DBP levels that are greater
than or equal to the 90th percentile, but
less than the 95th percentile
Adolescents with BP levels greater than or
equal to 120/80 mmHg should be
considered pre-hypertensive
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
Assessing for Hypertension in
Children & Adolescents
Approximately 9-13% of overweight children
have elevated blood pressure
Approximately 30% of obese children
(BMI >95th percentile) have hypertension
Blood Pressure in Children
Lower than an Adult –
Normal Blood Pressures
•
•
•
•
•
•
•
4
6
7
8
9
10
11
91/52
94/56
96/57
98/58
100/59
100/60
102/61
•
•
•
•
•
•
12
13
14
15
16
17
104/62
106/63
107/64
109/65
110/66
110/66
(Selekman, 2006)
Hypertension Overview
New national data added to the childhood BP
database
Updated BP tables now include the 50th, 90th,
95th, and 99th percentiles by gender, age and
height
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
Blood Pressure Levels for Boys
by Age and Height Percentile
SBP (mmHg)
Percentile of Height
DBP (mmHg)
Percentile of Height
Age
BP
Year
%
tile
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
75th
90th
95th
12
50th
102
103
104
105
107
108
109
61
61
61
62
63
64
64
90th
116
116
117
119
120
121
122
75
75
75
76
77
78
78
95th
119
120
121
123
124
125
126
79
79
79
80
81
82
82
99th
127
127
128
130
131
132
133
86
86
87
88
88
89
90
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
Blood Pressure Levels for Girls
by Age and Height Percentile
SBP (mmHg)
Percentile of Height
DBP (mmHg)
Percentile of Height
Age
BP
Year
%
tile
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
75th
90th
95th
12
50th
101
102
104
106
108
109
110
59
60
61
62
63
63
64
90th
115
116
118
120
121
123
123
74
75
75
76
77
78
79
95th
119
120
122
123
125
127
127
78
79
80
81
82
82
83
99th
126
127
129
131
133
134
135
86
87
88
89
90
90
91
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
How To Use The BP Tables
1. Use the standard height charts to determine the
height percentile
2. Measure & record the child’s SBP and DBP
3. Use correct gender table for SBP and DBP
4. Find child’s age on the left side of the table
Follow the age row horizontally across the table
to the intersection of the line for the height
percentile (vertical column)
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
How To Use The BP Tables
5. For SBP percentiles in the left columns and for
DBP %tiles in the right columns:
– Normal BP = < 90th percentile
– Pre-hypertension = BP between the 90th- 94th
percentile or > 120/80 mmHg in adolescents
– Hypertension = BP  95th percentile on repeated
measurement
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
How To Use The BP Tables
6. BP > 90th percentile should be repeated twice at
the same office visit
7. BP > 95th percentile should be staged:
– Stage 1 = the 95th percentile to the
99th percentile plus 5 mmHg.
– Stage 2 = >99th percentile plus 5
mmHg.
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
Blood pressure in children - exercises
1.Boy - 10 y.o. 95th %tile for height – blood pressure
100/60
• Blood pressure is 50th percentile = normal
SBP (mmHg)
Percentile of Height
DBP (mmHg)
Percentile of Height
Age
BP
Year
%
tile
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
75th
90th
95th
10
50th
97
98
100
102
103
105
106
58
59
60
61
61
62
63
90th
111
112
114
115
117
119
119
73
73
74
75
76
77
78
95th
115
116
117
119
121
122
123
77
78
79
80
81
81
82
99th
122
123
125
127
128
130
130
85
86
86
88
88
89
90
Blood pressure in children exercises
2. Boy - 12 y.o. 50% %tile for height – blood
pressure116/70
• Blood pressure is 90th percentile = normal
SBP (mmHg)
Percentile of Height
DBP (mmHg)
Percentile of Height
Age
BP
Year
%
tile
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
75th
90th
95th
12
50th
101
102
104
105
108
109
110
59
60
61
62
63
63
64
90th
115
116
118
119
121
123
123
74
75
75
76
77
78
79
95th
119
120
122
123
125
127
127
78
79
80
81
82
82
83
99th
126
127
129
131
133
134
135
86
87
88
89
90
90
91
Blood pressure in children exercises
3. Girl 9 y.o. 90th %tile for height – blood pressure
118/76
• Blood pressure >90th %tile = prehypertension
SBP (mmHg)
Percentile of Height
DBP (mmHg)
Percentile of Height
Age
BP
Year
%
tile
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
75th
90th
9
50th
96
97
98
100
101
102
103
58
58
58
59
60
61
61
90th
110
110
112
113
114
116
116
72
72
72
73
74
75
75
95th
114
114
115
117
118
119
120
76
76
76
77
78
79
79
99th
121
121
123
124
125
127
127
83
83
84
84
85
86
87
95
th
Blood pressure in children - exercises
4. Girl 16 y.o. 25th %tile for height – blood pressure
126/80
• Blood pressure is >90th %tile = prehypertension
SBP (mmHg)
Percentile of Height
DBP (mmHg)
Percentile of Height
Age
BP
Year
%
tile
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
75th
90th
16
50th
108
108
110
111
112
114
114
64
64
65
66
66
67
68
90th
121
122
123
124
126
127
128
78
78
79
80
81
81
82
95th
125
126
127
128
130
131
139
82
82
83
84
85
85
86
99th
132
133
134
135
137
138
139
90
90
90
91
92
93
93
95
th
Classification of Hypertension
in Children and Adolescents
SBP or DBP Percentile
Normal
< 90th percentile
Prehypertension
90th percentile to < 95th percentile, or if BP exceeds
120/80 even if below the 90th percentile up to < 95th
percentile
Stage 1 hypertension
95th percentile to the 99th percentile plus 5 mmHg
Stage 2 hypertension
>99th percentile plus 5 mmHg
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
Classification of Hypertension
in Children and Adolescents
Frequency of BP Measurement
Normal
Recheck at next scheduled physical examination
Pre-hypertension
Recheck in 6 months
Stage 1 hypertension
Recheck in 1–2 weeks or sooner if the patient is
symptomatic; if BP is persistently elevated on two
additional occasions, evaluate or refer to source of care
within 1 month
Stage 2 hypertension
Evaluate or refer to source of care within 1 week or
immediately if the patient is symptomatic
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
Assessing for Hypertension in Children
& Adolescents - recap
1.
2.
3.
4.
5.
6.
7.

Choose appropriate cuff size
Take in upper right arm
Cuff should cover approx 2/3 of upper arm
Cuff bladder should cover 80–100 % of the arm
circumference
Adolescent – adult cuff size
Large adolescent - extra large cuff
Student should sit for 3-5 minutes in a quiet
environment before the BP is measured
Refer for BP above the 95th percentile for either
systolic or diastolic
Therapeutic Lifestyle Changes
• Weight reduction - primary therapy for obesityrelated hypertension. Prevention of excess weight
gain can limit future increases in BP. Dietary
modification strongly encouraged in children and
adolescents with pre-hypertension and
hypertension
• Physical activity can improve efforts at weight
management and may prevent future increase in
BP
• Family-based intervention improves success
Acanthosis nigricans type III
associated with obesity, insulinresistant states and endocrinopathy
• Acanthosis nigricans is a disorder
that may begin at any age
• Velvety thickening
• Gray to brown to black in body
creases
– Neck, armpits, groin
– Darker skinned people have darker
lesions
http://www.aocd.org/skin/der
matologic_diseases/acantho
sis_nigrica.html
(James, et al 2005)
Acanthosis Nigricans (AN)
• About 90% of children with type 2 have dark
shiny patches on the skin, most often found on
the back of the neck ("dirty neck") and in
axillary creases http://www.childrenwithdiabetes.com
• Most commonly found in Hispanics, Native
Americans, African Americans, AsianAmerican/Pacific Islanders
(Jones and Ficca, 2007)
Acanthosis Nigricans (AN)
• Most commonly associated with obesity or
polycystic ovarian disease in women
• Can occasionally be found in people who have
more serious underlying health problems or taking
certain medications
• Treatment of the underlying medical condition
usually resolves the skin lesions
What can be done about AN?
• Acanthosis Nigricans is a marker that
signals elevated insulin levels and a risk of
developing type 2 diabetes and other
conditions in the future
• Taking immediate action may help delay or
prevent the health conditions associated
with high insulin levels
AN / T2DM = further evaluation
• The current research does not support that AN
will lead to type 2 diabetes
(Jones and Ficca, 2007, CDC, 2005)
• Discuss findings with the student and family
• Refer the student to seek additional medical
advice (Jones and Ficca, 2007)
Typical Acanthosis Nigricans
of the Neck
Typical Acanthosis Nigricans
of the Axillae
Quick Weight, Activity, Variety, &
Excess Survey (WAVE) for Children
Evaluate eating practices:
•
quantity
•
quality
•
timing of food intake
•
identify foods/patterns of eating that may lead to
excessive calorie intake
A means for a quick assessment of diet and activity and may
be useful for some clinicians and children
http://bms.brown.edu/nutrition/acrobat/wave.pdf
Physical Activity Assessment
Assess daily activity levels
Include time spent on:
exercise and activity
sedentary behaviors, such as television, video
viewing, and computer use
Quick Activity, Variety, & Excess Survey (WAVE) For Kids
www.mypyramid.gov
MyPyramid.gov
The Dietary Guidelines for Americans, 2005, gives
science-based advice on food and physical activity
choices for health
MyPyramid Worksheet
Check how you did yesterday and set a goal to aim for
tomorrow
www.mypyramid.gov
Child History
 Increased thirst
 Snoring
 Exercise intolerance
 Increased hunger
 Acanthosis nigricans
 Increased urination
 Fatigue
 Blurred vision
 Weight gain
Family History
Diabetes risk factors:
 Parent or sibling diagnosed with diabetes
 Grandparent or aunt/uncle diagnosed with diabetes
 Mother diagnosed with gestational diabetes
Higher-known risk groups:
 African American
 Asian American
 Pacific Islander
 Native American
 Hispanic/Latino
 < 60 minutes/day of physical play or activity
 > 2 hrs of TV/computer/video game use/day
Family History
Family history of obesity & medical problems
Several obesity-related medical conditions are familial
Family history predicts type 2 diabetes mellitus or insulin resistance,
and the prevalence of childhood diabetes.
Cardiovascular disease and cardiovascular disease risk factors -(hyperlipidemia and hypertension) are also more common when
family history is positive.
Consider history regarding first- and second-degree relatives
(Barlow, 2007)
Key Components of a Healthy Lifestyle Education/Counseling
• 60 minutes of physical activity • Provide counseling / educate
every day
students, families / school staff
on the key components of a
• Recommended # of cups of
healthy lifestyle
fruits/vegetables per day
http://www.mypyramid.gov/
• Provide written diabetes
prevention materials in
• Limit high-fat / high-sugar
appropriate language(s) from the
food/drink
National Diabetes Education
• Encourage water intake
Program (NDEP)
• Limit “screen time” to less than
http://ndep.nih.gov/index.htm
2 hours per day