Download Exercise & Health for Specific Populations – BS3106

Childhood Obesity
Introduction.
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What is Overweight & Obesity?
Childhood obesity is one of the most serious
public health challenges of the 21st century. The
problem is global and is steadily affecting many
low- and middle-income countries, particularly in
urban settings. The prevalence has increased at
an alarming rate. In 2007, an estimated 22
million children under the age of 5 years were
overweight throughout the world. More than
75% of overweight and obese children live in
low- and middle-income countries.
Causes?
The fundamental causes behind the rising levels
of childhood obesity are a shift in diet towards
increased intake of energy-dense foods that are
high in fat and sugars but low in vitamins,
minerals and other healthy micronutrients, and a
trend towards decreased levels of physical
activity. Medical research carried out to help
determine the genetic cause of obesity is yet a
relatively new field of research however a
medical research by Loos, et al, (2003)
Consequences?
Overweight and obese children are likely to stay
obese into adulthood and more likely to develop
noncommunicable diseases like diabetes and
cardiovascular diseases at a younger age.
Overweight and obesity, as well as their related
diseases, are largely preventable. Prevention of
childhood obesity therefore needs high priority.
World Health Organization (2009).
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Recent Trends.
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Prevalence within different nations, socioeconomic, cultural, gender issues, …
Back this up with graphs and statistics. (last
20 year developments)
Hypotheses involved in assessing childhood
obesity (set-point / fat cell theory)
Somatotypes.
UK Statistics: In 2006, 16% of children aged 2 to 15 were
classed as obese. This represents an overall increase
from 11% in 1995. Despite the overall increase since
1995, the proportion of girls aged 2 to 15 who were
obese decreased between 2005 and 2006, from 18% to
15%. There was no significant decrease among boys
aged 2 to 15 over that period. Among children aged 2
to 10, 15% were classed as obese in 2006.
• Boys were more likely than girls to be obese (17%
compared to 15%). Which is not a common finding
• Of children aged 8 to 15 who were classed as obese, two
thirds (66%) of girls and 60% of boys thought that they
were too heavy. (NHS, 2006)
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National Statistics.
In 2006, boys were more likely than girls to meet the recommended
levels of physical activity with 70% of boys and 59% of girls
reporting taking part in 60 minutes or more of physical activity
on all 7 days in the previous week.
• During 2006/07, 86% of pupils took part in at least two hours of
high quality PE and sport a week, a gradual increase since
2003/04 when the figure was 62%.
(HSE, 2006) Summary
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Increasing obesity from 1995-2006 whilst overweight has
remained similar. (2006 3/10 children obese or obese)
Girls in the lowest income quintile were two and half times
more likely to obese than high income counterparts.
Children in households where the reference person had
a semi-routine or routine occupations were nearly twice
as likely to be obese compared with those in managerial
and professional households.
Girls living in overweight or obese households more
likely to be overweight or obese. Parental BMI does not
correlate as well with boys.
Scotland found a higher rate of obesity among boys
than in England, little difference found in girls.
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National Statistics (2).
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Boys were more likely than girls to meet the recommended levels of physical activity. Participation
levels amongst boys remained broadly consistent with age while for girls participation generally
decreased with age.
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Information on participation rates showed that for boys active play (biking, football, running etc) was
the most common reported activity, whilst for girls walking was the most common activity.
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Parental physical activity levels were associated with children’s physical activity levels.
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Seven in ten pupils achieved at least 2 hours of physical activity a week as part of their curriculum.
Those in years 10 and 11 were the least likely to participate in 2 hours of PE as part of the curriculum.
(HSE, 2006)
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These findings correlate well with other findings such as the National Statistics Survey (2005). Again
using the UK National BMI percentile classification. Which is based upon six countries averaged data
The limitations of the international definitions, due to averaging data from different countries and the
choice of reference age, need to be known. The UK cut-off points here presented are compatible with
the current UK reference curves.
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UK BMI Table for Children.
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Socio-demographics
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www.dh.gov.uk (2009)
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Across the Globe.
(BBC, 2009)
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Main Body.
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What is overweight & obesity?
Overweight and obesity are defined as ''abnormal or excessive fat accumulation that presents a risk to health''.
Children aged 0 -5 years. (WHO Child Growth Standards)
WHO Multicentre Growth Reference Study (MGRS) – developed 1997-2003. (The MGRS collected primary growth data and related information from
approximately 8500 children from widely different ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA).
How can this be quantified?
:: Length/height-for-age
:: Weight-for-age
:: Weight-for-length
:: Weight-for-height
:: Body mass index-for-age (BMI-for-age)
:: Head circumference-for-age
:: Arm circumference-for-age
:: Sub scapular skinfold-for-age
:: Triceps skinfold-for-age
:: Motor development milestones
5 – 19 years. (Growth Reference Data).
Methods
Data from the 1977 National Centre for Health Statistics (NCHS)/WHO growth reference (1–24 years) were merged with data from the under-fives growth
standards’ cross-sectional sample (18–71 months) to smooth the transition between the two samples. State-of-the-art statistical methods used to construct
the WHO Child Growth Standards (0–5 years), i.e. the Box-Cox power exponential (BCPE) method with appropriate diagnostic tools for the selection of best
models, were applied to this combined sample.
Findings
The merged data sets resulted in a smooth transition at 5 years for height-for-age, weight-for-age and BMI-for-age. For BMI-for-age across all centiles the
magnitude of the difference between the two curves at age 5 years is mostly 0.0 kg/m² to 0.1 kg/m². At 19 years, the new BMI values at +1 standard
deviation (SD) are 25.4 kg/m² for boys and 25.0 kg/m² for girls. These values are equivalent to the overweight cut-off for adults (> 25.0 kg/m²). Similarly,
the +2 SD value (29.7 kg/m² for both sexes) compares closely with the cut-off for obesity (> 30.0 kg/m²).
Conclusion
The new curves are closely aligned with the WHO Child Growth Standards at 5 years, and the recommended adult cut-offs for overweight and obesity at 19
years. They fill the gap in growth curves and provide an appropriate reference for the 5 to 19 years age group.
The links below provide access to the reference charts and tables by indicator:
:: BMI-for-age (5-19 years)
:: Height-for-age (5-19 years)
:: Weight-for-age (5-10 years)
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Main Body (2).
The WHO Child Growth Standards provide a technically robust tool for assessing the well-being of
infants and young children. They were derived from children who were raised in environments that
minimized constraints to growth such as poor diets and infection. In addition, their mothers followed
healthy practices such as breastfeeding their children and not smoking during and after pregnancy. The
standards depict normal early childhood growth under optimal environmental conditions and can be
used to assess children everywhere, regardless of ethnicity, socioeconomic status and type of feeding.
Replacing the NCHS/WHO growth reference, which is based on children from a single country, with
one based on an international group of children recognizes the fact that children the world over grow
similarly when their health and care needs are met. In the same way, linking physical growth to motor
development underscores the importance of looking at child development comprehensively. Together,
three new elements — a prescriptive approach that moves beyond the development of growth
references towards a standard, inclusion of children from around the world, and links between physical
growth and motor development — provide a solid instrument for helping to meet the health and
nutritional needs of the world’s children.
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Current UK Policy – Early years, healthy start, sure start, and other school based initiatives.
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Policy Priorities – (For George).
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Main Body (4).
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Why does it matter?
cardiovascular diseases (mainly heart disease and stroke);
diabetes;
musculoskeletal disorders, especially osteoarthritis; and
certain types of cancer (endometrial, breast and colon).
These include problems with the joints and bones (such as slipped femoral epiphysis and
bow legs), a condition called benign intracranial hypertension that produces headaches
and affects vision, hypoventilation (leading to drowsiness during the day, snoring and
even heart failure), gall bladder disease, polycystic ovary syndrome, high blood pressure,
high levels of blood fats and diabetes.
There are also marked psychological effects leading to low self-esteem.
At least 2.6 million people each year die as a result of being overweight or
obese.
What are the causes?
A global shift in diet towards increased intake of energy-dense foods that are high in
fat and sugars but low in vitamins, minerals and other healthy micronutrients;
A trend towards decreased physical activity levels due to the increasingly sedentary
nature of many forms of recreation time, changing modes of transportation, and
increasing urbanization.
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Main Body (Consequences).
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Main Body (3).
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The concept of energy balance?
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Energy Intake (Nutritional) - Fat, G.I.,
Sugar & sugar sweetened soft drinks,
energy density & satiety, and ‘fast’ food
& portion size. (Comparison of French,
Mediterranean, & Italian diets).
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Energy Output (Physical) – School
Sport, Walking to school, Cycling to
school, sedentary pastimes,
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This is the factor that we are concerned
with today. Healthy eating is of the
utmost importance but only half the
equation.
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Main Body (…)
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Exercise Prescription for obese children –
(AHA / American Academy of Paediatrics – 60 minutes of vigorous-moderate activity each
day).
65%-80% of MHR.
Family influence is significant in making adequate long term adherence factors.
Encourage him/her to walk to school or the shops, rather than always going by car or bus.
Try to get the whole family involved in activities such as bike rides and swimming. You
could suggest going to the park for a game of football, cricket or Frisbee.
Visit a local leisure centre to investigate sports and team activities your child could get
involved in. Guides and Scouts are a good way to get your child involved in group activities
and exercise.
Make exercise into a treat by taking special trips to an adventure play park or an ice skating
rink, for example.
Encourage active playtime activities such as dancing or skipping.
Physically inactive pastimes, such as watching television or playing computer games, should
be limited to less than two hours a day. Encourage your child to be selective about what
he/she watches to reduce the amount of time spent watching television.
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Main Body – Types of
Exercise.
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Cardio vs. Resistance – Resistance
training has been found by
Research Digest (2007; Sothern et
al.,1999) to be a viable method of
training to improve health, fitness
and QoL. (Long term research is
necessary) – Consider Table 2.
A review by Sports Medicine
author Watts et al., (2005) found
that vascular improvements
outweighed direct weight loss. Also
that the preservation of lean body
mass is crucial as it accounts for
80% of RMR. (Improvements in
endothelial function > decreases
atherosclerosis). Increased insulin
sensitivity (Nassis et al., 2005).
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Main Body – Types of
Exercise (2).
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Key points on exercise – adherence, consistency, and FUN.
Less focus upon on mode of exercise & intensity.
Maintaining weight loss is the challenge.
Any activity is good.
Aim for children is FUN and enjoyment.
Aiming to monitor activity is a difficult process, direct observation is generally the best
method according to a review by Sirard & Pate (2001), but can be difficult across long periods
so accelerometers are a promising alternative.
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Main Body (Critical
Analysis).
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So is exercise enough? The general consensus is no, take for example the concept of energy balance –
Deckelbaum & Williams, (2001). Wrote that in an average 165 kg (75 lb) child expenditure equalled, 90, 525,
135, & 180 for bicycling, running, walking & dancing respectively, and that a regular McDonalds meal equated to
~600 calories and super sized meals ~1800 calories. These numbers show that to cover these requirements
would take a significant proportion of time to achieve a balance.
The necessary requirement is to prevent within the early stages of development, Denghan et al., (2005)
recommendations are adequate but how realistic? Some interventions strategies that could be considered for prevention of
childhood obesity I. Built environment
1. Walking network
a. Footpaths (designated safe walking path)
b. Trails (increasing safety in trails)
2. The cycling network
a. Roads (designated cycling routes)
b. Cycle paths
3. Public open spaces (parks)
4. Recreation facilities (providing safe and inexpensive recreation centers)
II. Physical activity
1. Increasing sports participation
2. Improving and increasing physical education time
3. Use school report cards to make the parents aware of their children's weight problem
4. Enhancing active modes of transport to and from school
a. Walking e.g. walking bus
b. Cycling
c. Public transport
III. TV watching
1. Restricting television viewing
2. Reducing eating in front of the television
3. Ban or restriction on television advertising to children
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Main Body (Critical
Analysis) (2).
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Studies on decreased sedentary behaviours as an adjunct within treatment have shown great promise
(Epstein et al., 2000). A 2 year study offered increased aerobic fitness, and lowered % body fat.
School based interventions are an excellent way of aiding treatment as children spend a huge % of
time in the taught environment. Conflicting evidence from OFSTED reports claim partnerships schools
are raising the standard (TeacherNet, 2009) with schools meeting targets at faster rates than expected
with the 5 hours per day target in 2010 coming ever closer. So can it be sustained or are misreporting
of data effecting these outcomes according to opposition party (Lib Dems, 2009).
Targeting younger children has been shown to be more effective long term results in preventing weight
gain as weight loss is more difficult with adolescents, due to eating patterns and P.A behaviour
becoming more difficult to change as age progresses (Carter, 2002).
Active Commuting to School initiatives.
Fat consumption has decreased over the last decade, but still obesity is rising, pre-disposition through
genetics is inherent which causes a cycle of juvenile obesity with accompanying low PA levels.
We can learn from studies across the Atlantic a representative sample of Canadian children (n=7216),
Tremblay & Willms, (2003) studied the links between P.A., obesity & overweight & sedentary
behaviours with SES, and family backgrounds. It positively identified low SES and single parent families,
along with sedentary behaviours. Contrary to this Wang (2001) found that it varies internationally.
Consensus is drawn to parent and school initiatives, with children & schools in low income areas
receiving priority to reduce socioeconomic inequalities in health (Veugelers & Fitzgerald, 2005)
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Future Research.
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What can be done? Action & Prevention. (Change 4 Life, NHS 2009)
Overweight and obesity, as well as related noncommunicable diseases, are
largely preventable.
It is recognized that prevention is the most feasible option for curbing the
childhood obesity epidemic since current treatment practices are largely
aimed at bringing the problem under control rather than effecting a cure. The
goal in fighting the childhood obesity epidemic is to achieve an energy
balance which can be maintained throughout the individual's life-span.
increase consumption of fruit and vegetables, as well as legumes, whole
grains and nuts;
limit energy intake from total fats and shift fat consumption away from
saturated fats to unsaturated fats;
limit the intake of sugars; and
be physically active - at least 60 minutes of regular, moderate- to
vigorous-intensity each day that is developmentally appropriate and involves
a variety of activities. More activity may be required for weight control.
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Future Research (2).
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Maintaining a healthy weight
In most cases, experts recommend that overweight children should not be encouraged
to actually lose weight. Instead they should be encouraged to maintain their weight, so
that they gradually "grow into it" as they get taller.
Children should never be put on a weight loss diet without medical advice as this can
affect their growth. Unregulated dieting - particularly in teenage girls - is thought to lead
to the development of eating disorders.
There isn't much evidence for the best ways to treat weight problems in children, but
research indicates that focusing on making long-term improvements to diet and
increasing physical activity may be the effective solution.
Helping children to achieve and maintain a healthy weight involves a threefold approach
that encourages them to:
eat a healthy, well-balanced diet
make changes to eating habits
increase physical activity - in 2004 the Chief Medical Officer recommended at least 60
minutes of at least moderate physical activity a day for children
The good news is that it is probably easier to change a child's eating and exercise habits
than it is to change an adult's.
(www.bupa.co.uk, 2009)
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Conclusion.
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Role of Parents
Role of Schools
Role of Member States
Role of WHO
Role of Civil Society and NGOs
Role of the Private Sector
‘interventions at the family or school level will need to be matched by changes
in the social and cultural context so that the benefits can be sustained and enhanced.
Such prevention strategies will require a coordinated effort between the medical
community, health administrators, teachers, parents, food producers and processors,
retailers and caterers, advertisers and the media, recreation and sport planners, urban
architects, city planners, politicians and legislators’. (BMA, 2009)
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Conclusion (2).
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Home
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School
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Urban design
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Health care
Marketing and media
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Politics
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Set aside time for
Healthy meals
Physical activity
Limit television viewing
Fund mandatory physical education
Establish stricter standards for school lunch programmes
Eliminate unhealthy foods—e.g., soft drinks and candy from vending
machines
Provide healthy snacks through concession stands and vending machines
Protect open spaces
Build pavements (sidewalks), bike paths, parks, playgrounds, and
pedestrian zones
Improve insurance coverage for effective obesity treatment
Consider a tax on fast food and soft drinks
Subsidise nutritious foods—e.g., fruits and vegetables
Require nutrition labels on fast-food packaging
Prohibit food advertisement and marketing directed at children
Increase funding for public-health campaigns for obesity prevention
Regulate political contributions from the food industry
(Ebbeling et al., 2002)
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Reference List.
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Baird, J., Fisher, D., Lucas, P., Kleijnen, J., Roberts, H., and Law, C. (2005). Being big or
growing fast: systematic review of size and growth in infancy and later obesity
Cole, T.J., Bellizzi, M.C., Flegal, K.M., & Dietz, W.H. (2000). Establishing a standard
definition for child overweight and obesity worldwide: international survey. British Medical
Journal. 320, 1240.
Deckelbaum, R.J., & Williams, C.L. (2001). Childhood Obesity: The Health Issue. Obesity
Research. 9, s239–S243
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Ebbeling, C.B., Pawlak, D.B., & Ludwig, D.S. (2002). Childhood obesity: public-health
crisis, common sense cure. The Lancet. 360, 473-482.
Funatogawa, I., Funatogawa, T., & Yano, E. (2008). Do overweight children necessarily
make overweight adults? Repeated cross sectional annual nationwide survey of
Japanese girls and women over nearly six decades
Kipping, R.R., Jago, R., & Lawler, D.A. (2008). Obesity in children. Part 1: Epidemiology,
measurement, risk factors, and screening. British Medical Journal. 337, 1824.
Lagstrom, H., Hakanen, M., Niinikoski, H., Viikari, J., Ronnemaa, T., Saarinen, M.,
Pahkala, K., Simell, O. (2008). Growth Patterns and Obesity Development in Overweight
or Normal-Weight 13-Year-Old Adolescents: The STRIP Study. Pediatrics 122: e876-e883
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Reference List (cont).
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Must, A., and Strauss, R.S. (1999). Risks and consequences of childhood and adolescent
obesity. International Journal of Obesity. 23, s2-s11.
Scharoun-Lee, M, Kaufman, J S, Popkin, B M, Gordon-Larsen, P (2009). Obesity,
race/ethnicity and life course socioeconomic status across the transition from
adolescence to adulthood. J. Epidemiol. Community Health 63: 133-139
Wardle, J., Henning-Brodersen, N., Cole, T.J., Jarvis, M.J., and Boniface, D.R. (2006).
Development of adiposity in adolescence: five year longitudinal study of an ethnically and
socioeconomically diverse sample of young people in Britain. British Medical Journal.
332, 1130-1135.
Whitaker, R.C., Wright, J.A., Pepe, M.S., Seidel, K.D., & Dietz, W.H. (1997). Predicting
Obesity in Young Adulthood from Childhood and Parental Obesity. New England Journal
of Medicine, 337, 869-873.
Jotangia, D. Moody, A. Stamatakis, E. Wardle, H. (2005) ‘Obesity among children under 11’
Date Retrieved on 9/04/2009 from the World Wide Web:
http://www.erpho.org.uk/Download/Public/12227/1/ObesityAmongChildrenUnder11.pdf.
Loos, R.J.F. Bouchard, C. (2003) ‘obesity- Is it a genetic disorder’ Journal of internal medicine,
254, .401-425
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