Addressing Obesity in and out of the Office:

The Pediatric Obesity Initiative at the Cleveland Clinic Children’s Hospital

Ellen Rome, MD, MPHHead, Section of Adolescent Medicine

Physician Leader, Pediatric Obesity Initiative

Why We Care

Obesity is currently the single most prevalent chronic disease in childhood.

The Scope of the Problem• Genes and jeans- what we inherit and what

we buy/feed our kids• For now, we can’t modify the genes part• HOW WE EAT: Patterns of eating learned

from parents first, then from families, peers, society

• Prevention of obesity is HIGHLY DEPENDENT on family dynamics

• Treatment of obesity is HARD!!!!!

Definition of Obesity• Occurs when:

energy intake > energy expenditure• Body Mass Index = wt (kg)/(ht in meters)2

• BMI 20-23 ideal for teens/adults• 120% of more of ideal body weight

or BMI > 95% defined as obese• BMI > 30 = obesity in teens and adults• BMI >95% = obesity in younger children

Prevalence of Overweight (>95%)

Prevalence of Overweight (>95%)

Prevalence of Overweight (>95%)

Prevalence of Overweight (>95%)

1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2007

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2007

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: CDC Behavioral Risk Factor Surveillance System.

Risk of Adult Obesity

• 14% chance if obese as infant• 25% chance if obese at preschool

age• 41% chance in obese at age 7• 75% chance if obese at age 12• 90% chance if obese in adolescence

Why We Care:Consequences of Obesity

• Hypertension (2.9 x higher in obese)• Diabetes (2.9 x higher in obese)• CAD• Hypercholesterolemia (2.1x higher)• Other hyperlipidemias• Mechanical stress on joints, SCFE• Blount’s disease (tibia vara)• Pseudotumor cerebri• Hepatic steatosis, cholelithiasis• Social stigma- depression, low self esteem

IF YOU REDUCE BMI by 10%…

• BP decreases by 10 mm/HG (average)• TGs decrease below 100 mg/dl or by

200 (if genetic defect present)• HDL-C raised by 3-5 mg/dl• LDL-C sometimes lowered (diet/wt

loss combined can lower LDL by 25-30% if elevated)

What is Adipose Rebound?• In 1st few yrs of life, have low adiposity -->

then begins to increase• Usually occurs between 4-6 yrs• The younger/heavier the child is at adipose

rebound, the more likely to become an overweight adult

• “…the adipose cells accumulated during this period will forever call out to be fed (Arriza, Peds Annals 2004)

Cleveland Clinic Pediatric Obesity- Key Objectives

• Obesity prevention is part of every routine child health supervision visit

• Increase clinical skill in identifying and treating overweight and obese children, including comorbidities

• To expand our services for pediatric and adolescent obesity in our region, particularly for our underserved youth- in the community

• To enhance care for the pediatric bariatric surgery patient

• To perform outcomes analyses to measure impact of our program

Food Advertising• On average, children ages 8-12 years see

7,600 food commercials a year• Food ads work• Almost all advertised foods are healthy

–97.5% food ads are shown Sat am – promote high fat, high sugar, high cholesterol

• Studies show that commercials increase liking for advertised foods

Power of the Media• Kids only need to see an ad once or twice to

influence their preferences• “Pester power” – increases kids’ demands

of their parents

Teaching Media Literacy• What’s wrong with this ad?• 1/3 less sugar means

– Higher fat– Higher sodium– Higher calories– Only lower in carbs by

1 gram– “Sugar” is a dirty word

for parents

When To Do an Intervention?

• Won’t work until child is ready to change; may actually do harm if done before child ready!

• With the very young child, just need parents’ willingness to modify diet/exercise to ensure success

• Can use motivational interviewing• May need family therapy, esp if

parent with eating disorder

An Example- Janice

• Janice comes to your program/office/facility. At age 10 years old, she has a BMI already of 30. Since kindergarten, she has been teased about her weight by peers, siblings, and extended family.

• Parents/You want to protect her from low self esteem- what can you do???

Teasing and OverweightProject EAT

• Assume overwt child or teen has been a victim of weight related teasing

• Nearly half of girls in PROJECT EAT were teased by their family

• Numbers likely an underestimate of what is happening-

Dinner time talk…

• What kinds of things do you like about family meals in your home? What would you like to change?- Stay on safe, non weight related topics- The Special Plate

• What are some ideas for making change happen?

Cut Out the Weight Talk

• Encourage families not to engage in wt talk, about the child or themselves

• Talking about wt, encouraging kid to diet/lose wt, wt teasing

• “Oh my gosh, I look fat!” “You have to go on a diet, get off that couch now!”

• “Talk less. Do more”. To make your home environment more conducive to healthy eating, incr phys activity, high self esteem

With Children and Teens• Let kids know that dieting and esp unhealthy wt

control behaviors may be counterproductive• Help kids feel better about their bodies regardless

of their size. If has child who is not a good reader, don’t want to make them feel stupid to help them read more… Do not use body dissatisfaction as a motivator for change.

• Encourage family to have regular, enjoyable family meals

• Assume overwt child has experienced wt related teens and address with children and their families

Janice

• When you ask Janice, she says that the teasing does bother her. She has thought about dieting and has cut out candy for the most part. She has switched from pop to juice to be healthy. She would not mind working on it with you.

• How do you proceed?

What Can You Do?

• Focus on strategies that increase physical activity, healthy eating and weight control behaviors, sources of social support, and issues of weight-related stigmatization + self-esteem

• Build exercise into family life/activities• HELP FAMILIES MAKE A FEW SMALL,

PERMANENT CHANGES AT A TIME

Cleveland Clinic’s Countdown to Health: 5 to GO!

• 5 a day fruits and veggies• 4 dairy/calcium servings a day for teens• Give and get 3 compliments a day• 2 hrs or less tv/media time• 1 hr exercise/activity a day• 0 sugar-sweetened beverages

Stoplight Diet• Red foods- avoid!• Yellow foods-

proceed with caution

• Green foods- GO!

Typical Behavioral Intervention

• Identify the problem: too many RED foods

• Brainstorm: Who is buying RED foods? Who brings RED foods home? Are there RED foods that could be

changed to yellow or green?• Generate solutions: Plan weekly meals;

buy healthy foods; make lunch rather than school lunch

The Role of Physical Activity in Weight Control

• Dose to prevent obesity is unknown• Dose to maintain weight after loss around

1 hr/day• Relatively modest impact on weight loss• Reduces obesity associated comorbidities• Built environment needs to be conducive…

School-Based Reforms-Age Specific CurriculumFood is Knowledge: (ages 4-6 yrs)

Ten interactive lessons teaching students about food groups using cute characters, songs and poems. Teaches math, science, social studies, culture and hospitality.

Healthy Futures: (grades 4-6). Ten week interactive wellness program that teaches students positive health-related behaviors.

HealthCorps: (grades 9-12). In/after school seminars on diet,

nutrition, exercise, mental health.Legislative efforts- school-based

reform on PE requirements, vending machine/food service, BMI screenings

Parent/Teacher Campaign Bully-proofing

Community Initiatives- Access to GO! foods & Affordable Shopping- Partner with local grocery stores with cooking

demonstrations, promote family dinners, Farmer’s Market to improve access to fruits/veggies

- Community Coalitions- Ohio Business Round Table partnership fostering legislation

- BMI Study- 17 inner ring suburbs, K-5th- Active Living Communities- Walking school bus- Built Environment: Playgrounds, green

spaces, bike paths, other efforts

Clinical Care- Fit Youth Programs for 8-12 yo’s,

13-18yo’s with BMI > 30, Weekly for 10 weeksParental involvementPsychology, MD, Dietitian, Exercise Physiologist

- 5 to GO! messaging in the office via motivational interviewing, from preconception on

- Protein Sparing Modified Fast (MD + dietitian monthly)

- Bariatric Surgery

Ages Birth to 22

Cleveland Clinic Employee Benefits- Trans fat free campus- Healthy vending machine/food

service offerings- Free Curves, Weight Watchers,

Fitness facilities- Wellness incentives: Go FIT!

School-Based Interventions:Curriculums

Food is Knowledge: (4-6 years). Ten interactive lessons teaching about the food groups using illustrated characters, songs, and poems. Uses food to reinforce math, social studies, language arts, science, art, culture.

Healthy Futures: (grades 4-6). Ten week interactive wellness program that teaches students positive health-related behaviors. Topics include physical activity, nutrition, bone health, substance abuse, safety, and mental health.

HealthCorps: (grades 9-12). In/after school seminars on diet, nutrition, exercise, mental health. Includes walking program, speakers, field trips, interactive experiences.

“One is good, two’s okay,Save the rest for another day!”

“Mealtime” from Food is Knowledge

Mealtime at our house is so much fun!We all sit together ‘til we are done.We don’t just eat and run- run away…We sit and talk about what we do all day.So please tell your familyTo share in their meal,With love for each memberAnd tell ‘em how you feel.For mealtime is not just the food you eat…It’s the sharing in your heartAnd the caring when you meet.

BMI Study: Lakewood Community Findings

• 4th graders screened and interviewed, nutrition and physical activity habits surveyed, BMI measured.

• 98/400 students overweight, 55 “at risk”• Correlating with BMI: low fruit, high junk food

consumption• “At risk” kids had lower SES, lower academic

achievement, and higher BMI• Limitations: NOT IRB approved, and reports

correlations, NOT causation• Expanding BMI study to all of Cleveland’s greater

ring suburbs

Fit Youth at Independence

• N = 72 children completed 10 week program:• Cumulative weight loss of group = 297 lbs• Average weight loss during group= 4.4 lbs• Greatest loss = 25.3 lbs• Greatest gain = 4.62 lbs• Percent who lost wt = 73.1%• Percent who gained wt = 25.4%• Percent who maintained= 1.5%

Using the Tobacco Analogy• 25% of health care costs due to obesity-related

morbidities• Solving the problem requires both policy and

environmental changes implemented at the state and community level

• Sidewalks, bike paths, safety- Fairfax project• School: healthy food, vending machine options,

physical education requirements, after school programming (Cleveland Clinic as example)

• Medical home helps, affordable/accessible meals, in school food that is healthy and fresh

Community Solutions• In the Workplace- Cleveland Clinic examples- transfat

free, healthy options everywhere, no smoking, walking areas, Curves, Weight Watchers…

• Policy: promote tax incentives for supermarket development and urban gardening in low-income neighborhoods

• Encourage fast food restaurants to promote healthier options

• Promote breastfeeding and smoke free pregnancies!• Create a bully-proof, tease-free environment!!!

New York City Daycare Laws

• TV, video and other visual viewing rules– No TV for <2yo– Limited 60 min per day of educational

programs or programs that actively engage child movement for kids >2yo

• 60 min physical activity required• Eliminated sugar-sweetened beverages• Provide 1% or no fat milk

Simple Messaging for Families• Family dinner counts!• Stop the weighty talk- and no teasing!• Change the built environment to make

family and child activity inevitable and easy• Teach media literacy- decrease the “pester

power”• In growing children, weight maintenance

alone may be a good goal

We Can Hopefully Avoid This…