Obesity prevention and education for school nurses

Obesity Prevention and Education for School Nurses
Dr. JayeshPatidar
www.drjayeshpatidar.blogspot.com

The planning committee & faculty attest that no relevant financial, professional orpersonal conflict of interest exists, nor was sponsorship of commercial support obtained, in the preparation or presentation of this educational activity. 9/17/2014
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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 Acanthosisnigricansand 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.
9/17/2014
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Obesity Trends
9/17/2014
4www.drjayeshpatidar.blogspot.com

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.
9/17/20145

Obesity / Overweight in Children
•Obesityin children / youth refers to age and gender-specific BMI that is equal to or greater than the 95thpercentile of the CDC BMI charts
•Overweight/at risk for obesitybetween 85th–94thpercentile
(IOM, 2007) 9/17/20146

In the Past Three Decades…
Number of overweight:
•6-11 year olds tripled
•Adolescents tripled (Gerberding & Marks, 2004)
•Overweight adults tripled (>60%)
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Obesity in Children
16.3%of childrenand 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)
9/17/2014

Obesity in the United States
http://www.cdc.gov/obesity/data/trends.html
9/17/2014 www.drjayeshpatidar.blogspot.com 9

20099/17/2014
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Trends in Obesity Among Boys9/17/201411

Trends on Obesity Among Girls
9/17/2014
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9/17/201413

•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 Obesity9/17/2014
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Risk Factors for Obesity9/17/2014
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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
9/17/2014

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
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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
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
Risk Factors for Obesity:
 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
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Consequences of Obesity9/17/201423

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
9/17/201426

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
9/17/2014
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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)
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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.
9/17/201429

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
9/17/2014
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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 are…more 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 ↓ activity…for children (F as in Fat, 2009)
Recap: Rising obesity rates -result of a number of trends in the US9/17/2014
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Assessing the Overweight/Obese Child9/17/2014
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Assessment of the Overweight and Obese Child and Adolescent
•Hypertension
•Acanthosis Nigricans
•Nutrition and Physical Activity
•Child and Family History
•Height/Weight/BMI
9/17/2014
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Definition of Hypertension
Average Systolic blood pressure (SBP) [higher number]and/or diastolic blood pressure (DBP)[lowernumber]that is ≥ to the 95thpercentile for gender, age and height on 3 or more occasions
9/17/201435www.drjayeshpatidar.blogspot.com

Definition of Pre-Hypertension
Average SBPor DBPlevels that are greater than or equal to the 90thpercentile, but less than the 95thpercentile
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
9/17/201436

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
9/17/201437

Blood Pressure in ChildrenLower 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) 9/17/201438www.drjayeshpatidar.blogspot.com

Hypertension Overview
New national data added to the childhood BP database
Updated BP tables now include the 50th, 90th, 95th, and 99thpercentiles by gender, age and height
9/17/201439

Blood Pressure Levels for Boysby Age and Height Percentile
Age
BP
SBP(mmHg)
Percentile of Height
DBP(mmHg) Percentile of Height
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
9/17/201440

http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htmBlood Pressure Levels for Girls by Age and Height Percentile
Age
BP
SBP(mmHg)
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
9/17/2014

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)
9/17/2014

5.For SBP percentiles in the left columns and for DBP %tiles in the right columns:
–NormalBP = < 90thpercentile
–Pre-hypertension= BP between the 90th-94thpercentile or > 120/80 mmHgin adolescents
–Hypertension= BP 95thpercentile on repeated measurement
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htmHow To Use The BP Tables
9/17/2014

6.BP > 90thpercentile should be repeated twice at the same office visit
7.BP > 95thpercentile should be staged:
–Stage 1 = the 95thpercentile to the 99thpercentile plus 5 mmHg.
–Stage 2 = >99thpercentile plus 5 mmHg. http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htmHow To Use The BP Tables9/17/2014
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Blood pressure in children -exercises
1.Boy -10 y.o. 95th%tile for height –blood pressure 100/60
•Blood pressure is 50thpercentile = normal
Age
BP
SBP(mmHg)
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
9/17/2014
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2. Boy -12 y.o. 50% %tile for height –blood pressure116/70
•Blood pressure is 90thpercentile = normal
Blood pressure in children - exercises
Age
BP
SBP(mmHg)
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
9/17/2014
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3. Girl 9 y.o. 90th%tile for height –blood pressure 118/76
•Blood pressure >90th%tile = prehypertensionBlood pressure in children - exercises
Age
BP
SBP(mmHg)
Year
% tile
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
75th
90th
95th
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
9/17/201447

4. Girl 16 y.o. 25th%tile for height –blood pressure 126/80
•Blood pressure is >90th%tile = prehypertensionBlood pressure in children -exercises
Age
BP
SBP(mmHg)
Year
% tile
5th
10th
25th
50th
75th
90th
95th
5th
10th
25th
50th
75th
90th
95th
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
9/17/2014
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Classification of Hypertension in Children and Adolescents
SBP or DBP Percentile
Normal
< 90thpercentile
Prehypertension
90thpercentile to < 95thpercentile, or if BP exceeds 120/80 even if below the 90thpercentile up to < 95thpercentile
Stage 1 hypertension
95thpercentile to the 99thpercentile plus 5 mmHg
>99thpercentile plus 5 mmHg
9/17/2014
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Frequency of BP Measurement
Normal
Recheck at next scheduled physical examination
Pre-hypertension
Recheck in 6 months
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
Evaluate or refer to source of care within 1 week or immediately if the patient is symptomaticClassification of Hypertension in Children and Adolescents9/17/201450www.drjayeshpatidar.blogspot.com

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 80–100 % 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 95thpercentile for either systolic or diastolic
9/17/2014
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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 activitycan improve efforts at weight managementand may prevent future increase in BP
•Family-based intervention improves success
9/17/2014
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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/dermatologic_diseases/acanthosis_nigrica.html9/17/201453

•About 90% of children with type2 have dark shiny patches on the skin, most often found on the back of the neck ("dirty neck") and in axillary creaseshttp://www.childrenwithdiabetes.com
•Most commonly found in Hispanics, Native Americans, African Americans, Asian- American/Pacific Islanders
(Jones and Ficca, 2007) Acanthosis Nigricans (AN)
9/17/2014
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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
9/17/2014
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What can be done about AN?
•Acanthosis Nigricans is a marker that signals elevated insulin levels and a riskof 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
9/17/201456www.drjayeshpatidar.blogspot.com

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)
9/17/2014
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Typical Acanthosis Nigricans of the Neck9/17/201458

Typical Acanthosis Nigricans of the Axillae
9/17/2014
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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
9/17/2014
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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
9/17/2014
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Child History
Increased thirst
Snoring
Exercise intolerance
Increased hunger
Acanthosis nigricans
Increased urination
Fatigue
Blurred vision
Weight gain
9/17/2014

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
9/17/2014

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
9/17/2014
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Key Components of a Healthy Lifestyle - Education/Counseling
•60 minutes of physical activity everyday
•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
9/17/2014

Obesity prevention and education for school nurses

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