Obesity Prevention and Education For School Nurses

Obesity Prevention and Education for
School Nurses
Dr. Jayesh Patidar
www.drjayeshpatidar.blogspot.com
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.
9/17/2014 2 www.drjayeshpatidar.blogspot.com
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 95
th
percentile of the CDC BMI charts
Overweight/at risk for obesity
between 85
th
94
th
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
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
The Epidemic of Childhood
Overweight and Obesity
Risk Factors for Obesity
Risk Factors for Obesity:
Diet Inactivity
High-calorie foods
High-fat foods dense
in calories
Soft drinks, candy,
desserts high in sugar
/ calories
Sedentary kids
more likely to
gain weight
Inactive leisure
activities
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
79%
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
0
10
20
30
40
50
60
70
80
Percentage
Preschool
School-age
Adolescent
(National Institute for Health Care Management, Nov 2003)
Some eat to cope with problems or deal
with emotions; stress or boredom
Parents may have similar tendencies
Psychological
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
Americans consume 300
more calories/ day than they
did 25 years ago & eat less
nutritious foods
Nutritious foods aremore
expensive than calorie-
dense, less nutritious foods
Americans walk less / drive
more -- even for trips of less
than one mile
Adults often work longer
hours & commute farther
Parks & recreation spaces
are not considered safe or
well maintained in many
communities
Many school lunches do
not meet nutrition
standards -children engage
in less physical activity in
school
screen time (TV, video
games) contributes to
activityfor children
(F as in Fat, 2009)
Recap: Rising obesity rates - result of a
number of trends in the US
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 95
th
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 90
th
percentile, but
less than the 95
th
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 91/52
6 94/56
7 96/57
8 98/58
9 100/59
10 100/60
11 102/61
12 104/62
13 106/63
14 107/64
15 109/65
16 110/66
17 110/66
(Selekman, 2006)
Hypertension Overview
New national data added to the childhood BP
database
Updated BP tables now include the 50
th
, 90
th
,
95
th
, and 99
th
percentiles by gender, age and
height
Blood Pressure Levels for Boys
by Age and Height Percentile
Age BP
SBP (mmHg)
Percentile of Height
DBP (mmHg)
Year
%
tile 5
th
10
th
25
th
50
th
75
th
90
th
95
th
5
th
10
th
25
th
50
th
75
th
90
th
95
th
12 50
th
102 103 104 105 107 108 109 61 61 61 62 63 64 64
90
th
116 116 117 119 120 121 122 75 75 75 76 77 78 78
95
th
119 120 121 123 124 125 126 79 79 79 80 81 82 82
99
th
127 127 128 130 131 132 133 86 86 87 88 88 89 90
Blood Pressure Levels for Girls
by Age and Height Percentile
Age BP
SBP (mmHg)
DBP (mmHg)
Year
%
tile 5
th
10
th
25
th
50
th
75
th
90
th
95
th
5
th
10
th
25
th
50
th
75
th
90
th
95
th
12 50
th
101 102 104 106 108 109 110 59 60 61 62 63 63 64
90
th
115 116 118 120 121 123 123 74 75 75 76 77 78 79
95
th
119 120 122 123 125 127 127 78 79 80 81 82 82 83
99
th
126 127 129 131 133 134 135 86 87 88 89 90 90 91
How To Use The BP Tables
1. Use the standard height charts to determine the
height percentile
2. Measure & record the childs SBP and DBP
3. Use correct gender table for SBP and DBP
4. Find childs 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)
5. For SBP percentiles in the left columns and for
DBP %tiles in the right columns:
Normal BP = < 90
th
percentile
Pre-hypertension = BP between the 90
th
- 94
th
percentile or > 120/80 mmHg in adolescents
Hypertension = BP 95
th
percentile on repeated
measurement
6. BP > 90
th
percentile should be repeated twice at
the same office visit
7. BP > 95
th
percentile should be staged:
Stage 1 = the 95
th
percentile to the
99
th
percentile plus 5 mmHg.
Stage 2 = >99
th
percentile plus 5
mmHg.
Blood pressure in children - exercises
1.Boy - 10 y.o. 95
th
%tile for height blood pressure
100/60
Blood pressure is 50
th
percentile = normal
Age BP
SBP (mmHg)
DBP (mmHg)
Year
%
tile 5
th
10
th
25
th
50
th
75
th
90
th
95
th
5
th
10
th
25
th
50
th
75
th
90
th
95
th
10 50
th
97 98 100 102 103 105 106 58 59 60 61 61 62 63
90
th
111 112 114 115 117 119 119 73 73 74 75 76 77 78
95
th
115 116 117 119 121 122 123 77 78 79 80 81 81 82
99
th
122 123 125 127 128 130 130 85 86 86 88 88 89 90
2. Boy - 12 y.o. 50% %tile for height blood
pressure116/70
Blood pressure is 90
th
percentile = normal
Blood pressure in children -
exercises
Age BP
SBP (mmHg)
DBP (mmHg)
Year
%
tile 5
th
10
th
25
th
50
th
75
th
90
th
95
th
5
th
10
th
25
th
50
th
75
th
90
th
95
th
12 50
th
101 102 104 105 108 109 110 59 60 61 62 63 63 64
90
th
115 116 118 119 121 123 123 74 75 75 76 77 78 79
95
th
119 120 122 123 125 127 127 78 79 80 81 82 82 83
99
th
126 127 129 131 133 134 135 86 87 88 89 90 90 91
3. Girl 9 y.o. 90
th
118/76
Blood pressure >90
th
%tile = prehypertension
Blood pressure in children -
exercises
Age BP
SBP (mmHg)
DBP (mmHg)
Year
%
tile 5
th
10
th
25
th
50
th
75
th
90
th
95
th
5
th
10
th
25
th
50
th
75
th
90
th
95
th
9 50
th
96 97 98 100 101 102 103 58 58 58 59 60 61 61
90
th
110 110 112 113 114 116 116 72 72 72 73 74 75 75
95
th
114 114 115 117 118 119 120 76 76 76 77 78 79 79
99
th
121 121 123 124 125 127 127 83 83 84 84 85 86 87
4. Girl 16 y.o. 25
th
126/80
Blood pressure is >90
th
%tile = prehypertension
Blood pressure in children - exercises
Age BP
SBP (mmHg)
DBP (mmHg)
Year
%
tile 5
th
10
th
25
th
50
th
75
th
90
th
95
th
5
th
10
th
25
th
50
th
75
th
90
th
95
th
16 50
th
108 108 110 111 112 114 114 64 64 65 66 66 67 68
90
th
121 122 123 124 126 127 128 78 78 79 80 81 81 82
95
th
125 126 127 128 130 131 139 82 82 83 84 85 85 86
99
th
132 133 134 135 137 138 139 90 90 90 91 92 93 93
Classification of Hypertension
in Children and Adolescents
SBP or DBP Percentile
Normal
< 90
th
percentile
Prehypertension
90
th
percentile to < 95
th
percentile, or if BP exceeds
120/80 even if below the 90
th
percentile up to < 95
th
percentile
Stage 1 hypertension 95
th
percentile to the 99
th
percentile plus 5 mmHg
Stage 2 hypertension >99
th
percentile plus 5 mmHg
Frequency of BP Measurement
Normal
Recheck at next scheduled physical examination
Pre-hypertension
Recheck in 6 months
Stage 1 hypertension Recheck in 12 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
Classification of Hypertension
in Children and Adolescents
Assessing for Hypertension in Children
& Adolescents - recap
1. Choose appropriate cuff size
2. Take in upper right arm
3. Cuff should cover approx 2/3 of upper arm
4. Cuff bladder should cover 80100 % of the arm
circumference
5. Adolescent adult cuff size
6. Large adolescent - extra large cuff
7. Student should sit for 3-5 minutes in a quiet
environment before the BP is measured
Refer for BP above the 95
th
percentile for either
systolic or diastolic
Therapeutic Lifestyle Changes
Weight reduction - primary therapy for obesity-
related 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, insulin-
resistant 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
(James, et al 2005)
http://www.aocd.org/skin/der
matologic_diseases/acantho
sis_nigrica.html
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, Asian-
American/Pacific Islanders
(Jones and Ficca, 2007)
Acanthosis Nigricans (AN)
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 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)
Family History
Key Components of a Healthy Lifestyle -
Education/Counseling
60 minutes of physical activity
every day
Recommended # of cups of
fruits/vegetables per day
http://www.mypyramid.gov/
Limit high-fat / high-sugar
food/drink
Encourage water intake
Limit screen time to less than
2 hours per day
Provide counseling / educate
students, families / school staff
on the key components of a
healthy lifestyle
Provide written diabetes
prevention materials in
appropriate language(s) from the
National Diabetes Education
Program (NDEP)
http://ndep.nih.gov/index.htm

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