Dataspeak -- April 2002 -- Transcript

"Obesity and Overweight in Children and Adolescents"
April 4, 2002

Welcome
Stella Yu, ScD
Maternal and Child Health Bureau

Logistics
Beth Zimmerman, MHS
MCH Information Resource Center

>> STELLA YU: Good afternoon, this is Stella Yu of the Maternal and Child Health Burear and on behalf of them, I'd like to welcome you to the Dataspeak conference. The Dataspeak conference is sponsored by the Bureau's MCH Information Center, of which I serve as the Project Officer. We are pleased that Dataspeak conferences were made available through the Internet as well as through the teleconference format. I'd like to extend a special thanks for the Center for the Advancement of Distance Education for developing the Internet component of this Dataspeak program. I'd like to also thank the CDC for providing the audio conference bridge for our telephone participants.

Today is the first of two programs in our 2002 Spring Series. Our next program on June 13 will discuss the health of immigrant populations, with a special focus on the children of immigrants living in the U.S. You can register for this program on the Dataspeak website. Today's Dataspeak addresses the important and timely public health issue of overweight and obesity in children and adolescents. Van Hubbard of the National Institute of Health will provide highlights of trends in overweight and obesity and strategies for addressing this issue, highlighting the importance of physical activity as a means of preventing and reducing childhood obesity. Dr. Bonnie Spear will talk about the guidelines for promoting physical activity for children and adolescents. I'd like to thank the presenters for their participation in today's program. It's now my pleasure to introduce Beth Zimmerman, the coordinator of Dataspeak and the moderator for today's program. Beth, I will now turn the floor over to you.

>> BETH ZIMMERMAN: Thank you and welcome to all of our participants. We had an enormous response for today's program. Over 450 people registered, and we are really glad to have you all with us and to see the high level of interest in the topic of childhood and adolescent obesity. The program will be archived and available on the Dataspeak website in about 2 days. If you know of others who would like to see the presentation, you can let them know about the resource.

I'd like to help everyone make the most of today's program. First, I want to be sure that everyone knows how to access the visuals that have been prepared to accompany our two presentations. Those of you who are listening to the broadcast through the Internet will be shown a slide presentation coordinated with the presenter's remarks. People on the phone or the Internet can also view the slides within the slide show section of the Dataspeak website, where you can manually scroll through them as the presenters talk. A third option is to view the slides through Power Point. For anyone who needs the Dataspeak website address, it is www.uic.edu/sph/dataspeak. I also want to point out that in order to coordinate the presenters' remarks with their slides for the Internet broadcast, and also for the archives, their presentations have been prerecorded.

After we hear both of their presentations we will have a question and answer session. Those of you who use the phone will have an opportunity to ask questions. At that time through the operator. In addition, everyone can post questions at any time during the program on the website. To post a question online, or to read what others have posted, from the Dataspeak website, you just click on the link on the home page for today that says "Read and submit questions and answers."

Now it's my pleasure to turn the floor over to Michelle Lawler of the Division of State and Community Health Programs, in the Maternal and Child Health Bureau. She will provide a brief introduction to today's program and an overview of the Bureau's role in this important area.

Overview
Michelle Lawler, MS, RD
Division of State and Community Health Programs
Maternal and Child Health Bureau

Thank you, Beth, and hello to everyone. I'm currently serving as a Nutrition Coordinator for the Maternal and Child Health Bureau and, in this capacity, I would like to welcome you to today's conference -- and to provide you with a brief overview of some of the bureau's activities related to this topic area. The issue of overweight and obesity in children and adolescents has become a national priority and we are certainly pleased to provide you with the Dataspeak conference on this timely issue. Certainly, I think the number of registrants that we have for this call today indicates a high level of interest in this topic. The Surgeon General's call to action to address overweight and obesity is a landmark document addressing this critical public health issue. And it does represent a national commitment of working together to combat the epidemic of overweight and obesity in the United States.

In the interest of time, I'm only going to briefly highlight a few of the Bureau's activities related to healthy lifestyles and obesity prevention. I hope that many of you are familiar with the Bright Futures project. The project was initiated in 1990, in an effort to help health professionals, families, and others who care for children, to be more effective in health promotion and disease prevention. The Bright Futures guidelines for health supervision of infants, children and adolescents was published in 1994. Now, included in the Bright Futures and practice series are guides for nutrition and for physical activity. And we are happy to say that the second edition of the Bright Futures Nutrition Implementation Guide and pocket guide are in the process of being developed and hopefully will be released soon.

The Bright Futures and Practice Guidelines for Physical Activity was published in 2001. Some other activities I'd like to mention: in the mid 1990s, the Bureau convened two advisory groups on promoting healthy weight among children. And then in 1997 the Bureau convened an expert committee, which was chaired by Dr. William Dietz, to develop recommendations for physicians, nurse practitioners and nutritionists to guide the evaluation and treatment of overweight children and adolescents. Based on the committee's recommendations, the Bureau supported the development of an assessment tool to determine the level of understanding and practice of physicians, nutritionists and nurses regarding childhood obesity. Now, this assessment was conducted in 1999. And it's my understanding that a series of articles highlighting the findings of the childhood obesity needs assessment are in final preparation for publication as a supplement in Pediatrics. I should also mention that the Bureau supports grants to institutions of higher learning in the area of nutrition leadership training and research. And I think you'll find that the discussions today are very timely and they do address a critical public health issue. I hope that you find that the strategies presented here today are useful, as we all begin to work together to try and address this epidemic. Thank you for your interest.

National Strategies Concerning Issues of Childhood Overweight and Obesity and Implications for Long-term Health
Van S. Hubbard, MD, PhD
Director, Division of Nutrition Research Coordination
National Institutes of Health

>> BETH ZIMMERMAN: Now we will hear from Van Hubbard, the Director of the Division of Nutrition Research Coordination for the National Institutes of Health. In this role, he is responsible for developing and managing research initiatives related to nutritional sciences and obesity. During his presentation he will provide an overview of data and issues related to childhood overweight and obesity. In his remarks, he will be referencing the Surgeon General's call to action to reduce obesity. It's dedicated to Dr. Paul Ambrose. He played a lead role in the development of this report and who was killed in the September 11 terrorist attacks. As we discuss overweight and obesity, Dr. Hubbard asks that we all remember Dr. Ambrose for addressing this important issue. Thank you for being here, Dr. Hubbard. Now I'll turn the floor over to you.

>> VAN HUBBARD: I hope to give you a quick overview of children's overweight and obesity and long-term health consequences. Next slide, please. First, in defining overweight and obesity, we have to cover the ground rules of a few issues. Ffirst, there is no definition for obesity for youth. We only use the term "overweight." Yes, some people are obese. However, we did not have a specific cut point for that determination. The other thing is that obesity is really excess body fat. But we are concerned about obesity because of the health consequences associated with excess body fat. Next slide.

And in correlation of health with overweight, we normally use BMI or Body Mass Index as a frame of reference. As everybody should be aware, Body Mass Index is weight (measured in kilograms) over height (as measured in meters) squared. BMI is an effective screening tool, but it's not a diagnostic tool. We have to use some type of cut point in determining the prevalence of overweight, and we select a cut point for that purpose. However, it is useful in looking at population trends. In looking at an individual, some other characteristics also need to be considered. Specifically for children, BMI is also age and gender specific. So BMI-for-age is generally the measure used. Next slide.

In May of 2000, the CDC issued new growth charts which for the first time included BMI curves for children ages 2 to 20. This is a depiction of one of these new BMI growth curves, and as depicted here, it is for males. There is a similar curve for females. As you can see, the BMI for a given percentile changes in numeric number with age, and thus the need to really plot out the information rather than remembering a single number as we do when we consider overweight and obesity in adults. Next slide.

With regard to nutritional status in youth, overweight is defined at or above the 95th percentile of BMI-for-age and gender. Using the 85th percentile, up to the 95th percentile, is the definition of at risk for overweight. Some advantages are for the use of BMI-for-age, it provides a reference for adolescents and younger youth that were not previously available. The 95th percentile of BMI approximates that BMI of 30 for adults, in a comparable way the 85th percentile BMI approximates a BMI of 25 in adults. The use of the BMI-for-age curve allows some tracking of childhood overweight into adulthood. This is a depiction of some data by Whittaker published several years ago and the important point made on this graph is the youth on this graph of BMI less than the 85th percentile, there is very little tracking to being obese at age 25, whereas for those that are either at risk or overweight, especially as they become teenagers, there is an increasing risk of that tracking to being obese as an adult. In terms of looking at BMI as a surrogate for obesity or increasing body fat, there is an excellent correlation between BMI and total body fat when viewed for the population. Again on an individual basis, there is a fair degree of variance, but there is a very strong correlation on a population basis. Next slide.

I want to take a few moments just to identify some of the health consequences and for this purpose much of the information is based on adult data. The general classification of obesity in adults is as shown on this slide, overweight is classified as BMI of 25 to 29. And obesity is BMI of 30 and above. Usually when we use the term "overweight" we are incorporating all those who are overweight and those that are considered obese. However, in certain statistics, we also want to separate out the two groups and we will identify those numbers specifically when used in that fashion. Next slide.

Many of you may have already seen the series of maps distributed by the Centers for Disease Control and Prevention depicting the increasing prevalence of overweight and obesity in the US over the last several years. This is a summary slide showing that same information from 1991 to 2000. In which as the shading of blue becomes darker and actually turns to red, it shows an increasing proportion of the population that is becoming obese. And again, this is a BMI of 30 or above. It's very dramatic that the problem is getting worse year to year and we have not seen the increasing prevalence slow down as of yet. Next slide.

In actual numbers, we are now approaching 61 percent of the adult population having a BMI of 25 or above. In terms of the number of people who are obese, it went from 15 percent from data (inaudible) to 27 percent in the most recent analysis of NHANES 1999 data. The same is true in children. This chart provides information about the increasing prevalence of youth, both children age 6 to 11, and adolescents age 12 to 19, who are at the 95th percentile or above the age and gender specific BMI (according to the BMI growth curves that were issued in May of 2000). Basically the increase in prevalence has gone from about 4 to 5 percent in the 60s and '70s, to 13 and 14 percent currently. I want to stress that the health risk associated with overweight and obesity increases as the degree of overweight increases. However, the health risk is part of a continuum. The risk is also influenced by the regional deposition of the fat tissue and especially the degree of visceral or intraabdominal adiposity. Just quickly, I want to show you a few slides regarding health risk, and that depicts the increasing mortality with increasing BMI, again, in adults. Next slide.

The mortality rate associated with obesity is 50 to 100 percent over that of normal weight individuals, with most of the increase due to cardiovascular disease. Here again, we show increasing risk of disease, in this case it's hypertension, with increasing BMI. Even at BMIs considered to be at the normal level in adults, there is still a step wise increase in risk. The rate of rise in the risk goes up more significantly once you get by a BMI of 25. There again, for diabetes, you can see an increasing risk of diabetes being present as BMIs go up. Again, there is a slight increase rate of rise in that risk as you get above BMIs of 25. In adults, it's been shown that independent of where your weight actually is, that if you gain weight you are at significantly increased risk of developing diabetes. Next slide.

Recently, in December of 2001, the Surgeon General released a Report on a Call to Action to Prevent and Decrease Overweight and Obesity. The overarching purpose of this report was to call the nation's attention to the epidemic of overweight and obesity in all age groups, in all ethnic and racial groups, and both genders, and to identify actions that we as a nation can undertake. Next slide.

This report was the first to really call attention to overweight and obesity as a public health priority. It placed emphasis on both prevention and intervention to improve health. And so doing it attempts to raise the awareness of the social, cultural, and environmental influences, in order to be successful in many of the prevention and intervention modalities. There is significant need for access to both family and community support. And we are calling on everybody to do their share to help. Next slide.

One of the concepts that has to be understood is that obesity is a chronic disease. Often it is treated as a subacute illness, however we need to have long-term treatment if we are going to be successful in sustaining any weight improvement that occurs following such short-term treatment. We also have to remember that there is a genetic component to obesity as well. This does not mean that certain people have no control over their health in association with their weight. Even though they may be predisposed to increasing weight there can still be many health benefits achieved by modification and improved lifestyle relating to dietary intake and physical activity. Some prevention and intervention strategies focus on modification toward more healthful lifestyles including increased purposeful activity, such as taking stairs or walking additional distances during the day, and at the same time we must decrease our sedentary behaviors, we need to have opportunities to improve our dietary choices and we must look for and make use of available support mechanisms. Some of the issues that we need to consider are the appropriateness of messages. In doing so, we have to be aware of the reading level, that they are racially and ethnically correct, and that they are scientifically sound. In making recommendations we should accept the fact that people from different cultures may have somewhat different behaviors, and look towards making some small changes, but make those changes within the patterns that are perceived as close to normal to those individual cultures. The next slide, please.

In terms of scientific sound messages, it would also be important that the messages come across as being consistent. There are many groups out there that are attempting to highlight differences in the messages, whether they are real or perceived differences, in order to generate controversy. Consequently, groups need to work together to make sure that their messages are clearly interpreted by all. We need additional motivation to adopt modified behavior. And again, the importance of appropriate and accessible options or choices needs to be stressed. If the consumer does not have appropriate choice to make or you make that choice too difficult to make, they aren't going to make it. Who needs to be involved? We have families, schools, businesses, healthcare organizations, communities, and the media. Even though we're trying to emphasize the issue relating to childhood overweight and obesity, nearly all of these components also may have an impact on our youth today. Next slide.

Again, in repeat of some earlier comments, at the families and communities level, we need to emphasize that we need to make our recommendations within the cultural and environmental aspects that the families and children find themselves. We have to be aware of some of the constraints to access to safe activity. And access to various support mechanisms. In school, we have issues relating to dietary choices as well as activity choices. There has been controversy and media attention to the issue of foods available and especially those food options available in vending machines. However, we have to also be aware of the family influences and where these kids are eating at other times during the day. With regard to activity, much of the activity that had been in place in the school system has been deleted and has been replaced by more academic options. We need to improve the availability of both improved dietary options as well as activity options for the youth today during the school day. We are attempting to emphasize the overall benefit of good dietary choices and good physical activity, yet in many schools we are not allowing any time to be spent in these areas -- to further demonstrate the priority that should be assigned to these activity. Next slide.

At the work site, we can also support the infrastructure for families and communities which will consequently have impact on our youth. We can collect data on work efficiency which also will be translated to efficiency of learning for our youth. Next slide.

In terms of healthcare, we need to recognize the trends that are developing of early weight gain that is inappropriate. Most of the time the current healthcare system does not focus on the increasing weight of the child until it has become extreme. If we focused on it earlier in the course of development, there may be an increased opportunity to do something beneficial that would be sustainable. Next slide.

Again, with regard to media and communications, we have to improve the recognition and translation of research findings into the media. We need to work with the media so that when conflict is presented, that it is presented with potential explanations. And we need to identify some success stories in the media as well. Next slide.

In order to achieve success, we need to partner among various groups -- in the healthcare area as well as in the community resource area. Many groups are consulting with the same experts, many groups are seeking support from common sources. Obviously the goals are overlapping. By working together we can improve consistency of these efforts and efficiency of the resources needed to carry out the efforts. Next slide.

Over time, we need to monitor our status. One of these programs within the nation that we are doing is Healthy People 2010. Overweight and obesity is identified as one of the leading health indicators and will be commented upon by use of an annual report card to show the current trends. We will also need to look at subpopulations. We need to be aware of some differences between measured versus self reported weight so that we don't get confused in the direction that we are moving when we see reports in which the data has been reflected using different methodology. We need to improve our ability to collect longitudinal data as well as cross-sectional data so that we can identify what is contributing to weight change. And most importantly, instead of focusing solely on weight, we need to look at the modification of health risk. In our youth today, we are seeing increasing blood pressures, we are seeing increasing blood lipids, and we are seeing increasing prevalence of Type II diabetes. We should be focusing on the health risks that we are observing and not solely on the weight. Next slide.

In summary, we need to focus on lifelong modification of behaviors. We need to be aware of the environmental influences that dictate behaviors. Prevention is the ultimate goal for those who are not overweight. And improved health is a goal for everybody. And as I have said repeatedly, everybody needs to do their share and become a partner. Next slide.

Let us all strive to make a difference, and carry on this battle to address overweight and obesity in this country. Thank you.

Empowering Youth Through Physical Activity: Using Bright Futures
Bonnie A. Spear, RD, PhD
Associate Professor of Pediatrics
University of Alabama at Birmingham

I'd like to thank Dataspeak and Maternal and Child Health Bureau for allowing me to speak about Bright Futures and the use of physical activity to empower you. Bright Futures' original guidelines help children. It's more than a set of guidelines, it's a unique approach to children's health and healthcare. They encourage professionals to recognize the needs of each child and family and help the children within the context of family and community. It's supported by the Maternal and Child Health Bureau. And it's under the management of the National Center for Education and Maternal and Child Health at Georgetown University.

The second in the series of Bright Futures is Bright Futures in Practice. The first book was Health and Nutrition and Physical Activity published in 1991. We will discuss the use of the activity book and how to incorporate that into a primary care setting. From the book, we do note from the Surgeon General's report that nearly half of adolescents ages 12 to 21 don't participate regularly in any rigorous physical activity. About 14 percent of children and adolescents didn't participate in light to moderate physical activity. Physical activity in children and adolescents has benefit and we will go through those a bit for the next few slides.

Physical activity increases bone mass and reduces the risk of osteoporosis. It helps to build greater bone density and helps maintain a peak bone mass in adulthood. This is a critical time to increase bone mass. But in order to do this, increase this, children and adolescents need to jump rope, walk, playing soccer or dancing or things like that. We also know from Dr. Hubbard that physical activity reduces the risk for obesity. It's crucial in maintaining a healthy weight, and physical activity helps reduce sedentary behaviors. It's getting kids up and getting moving and it helps to control blood sugars in children with Type II diabetes. Also, it lowers blood pressure. And children with elevated blood pressure, physical activity helps to lower both the systolic and diastolic blood pressures. It's been shown to improve blood lipids. In adults it increases those levels, particularly the HDL levels. Impact of physical activity on the HDLs in children is unclear, but higher HDLs have been seen in children that participate in regular physical activity. It also reduces anxiety and stress. Regular physical activity helps to promote psychological well-being and that is improving the children's self-esteem, reducing the level of anxiety and reduces symptoms of depression. It's unclear whether this is (inaudible) or whether it's due to Seratonin uptake during the exercise itself. Next.

But how do we get kids more active? This is where the physical activity book comes in. It gives guidance on how to promote it in a clinical setting. I'll go through some of the suggestions and concepts in the book. The Bright Futures is based on family matters, partners, care givers, resources. But in order for them to do this, they need knowledge and they need advice from the primary care providers. It's also based on health promotion and prevention. Physical activity is a wonderful prevention tool but healthcare providers cannot do this alone. They have to work with child care professionals, schools, third-party payors, to promote physical activity. The visions and goals of Bright Futures physical activity is to improve the health and physical status of infants, children and adolescents, and establish the physician guidelines focusing on physical activity.

The book can be used in many way -- in a clinical, community, policy, or education and training -- and we will go through those just briefly to show how these can be used. In a clinical setting, it can be incorporated into healthcare supervision visits, it can be used to implement standards of practice and protocol. And educate children and adolescents in the families. This guide can also be used in a community setting. It can provide anticipatory guidance to families on developmentally appropriate physical activity. It can help schools incorporate physical activity into the curriculum as well as implement standards of practice and protocol in the public health arena. It can also be used as policy it can provide information to policy makers, program administrators and community leaders on relevant physical activity issues and concerns and how to incorporate that into community programs. It also, the guide can be used as education and training. It can educate and train health professionals and paraprofessionals. It can be used to provide in service education for training and staff and used as textbooks or references. Many residency programs and nurse practitioners programs use all of the bright futures as textbooks in their training.

The Bright Futures and Physical Activity book is divided into four stages: infancy, early childhood, middle childhood and adolescence. It also incorporates a variety of activity issues and concerns chapters, which include things such as eating disorder and diabetes, female athletes, injury, obesity and things like that. But probably the most critical part is that it shows what is appropriate developmentally at the different age groups. Look at a chart from the middle childhood chapter. For ages five to six, the motor skills are fundamental: running, galloping, catching, kicking, those things. Appropriate activity should focus on having fun and developing motor skills rather than competition. And simple activities that require little instructions. Repetitive activities are also important at this age group.

For the 7 to 9 year old, we still need to work on fundamentals, but they can start transitioning from just the act of throwing to throwing for accuracy. Activities again need to be flexible rules; activities don't require complex motor or cognitive skills. They don't need to be learning how to do plays or that type of thing. That would be too complex and confusing. Again, activities that require little instruction.

For the 10 to 11 year old who is now becoming more and more developed, again we do transitional skills, but they can start learning complex play skills, such as playing basketball, where you have to learn plays and activities. Activities that focus again on the developing motor skills, but that can have more entry level complex motor skills, learning a series of complex moves in order to play the activity. Activity continues to emphasize motor skill development, because children at this age are still growing developmentally and increasing their muscle mass as well.

The book gives ideas of how to incorporate physical activity questions into the clinical visits. Are there any physical activities you enjoy and don't participate in? If so, which ones and why? Do you feel good about that physical activity? Are you good at it? If so, which ones or why. This gives the practitioner the idea that if the child feels that they are not good, maybe they can find things that they are good at. If they are not good at sports, maybe biking or hiking would be something they enjoy. And of course asking about watching TV or sedentary activities.

It also gives guidance about the BMI and how to use that. But I think if you're looking at the physical activity count, even if the child is not at risk for overweight, which is the BMI less than 86 percent, physical activity needs to be part of the counselling as a preventive school. Once at risk, which is between 85 and 95th percentiles, there needs to be more intensive talk about physical activity and more guidance and counselling in that area. Once a child is overweight, which is a BMI greater than 95th percentile, then we have to really talk about some really long-term physical activity and really do some long-term counselling in that area. The book recommends treating uncomplicated obesity with healthy eating behaviors, having physical activity and achieving psychological well-being and today we will concentrate on the regular physical activity and how to do the counselling around that.

Physical activity counselling should begin early. It is recommended that parents focus on gradually changing the entire family's physical activity behavior, not just the child in question. And we encourage children and adolescents to participate in physical activities they enjoy. Often parents want them to participate in things that the children don't enjoy, like sports, whereas they may enjoy biking or swimming, more individual activities that parents hadn't thought about. And that's where the role of the practitioner comes in. And encouraging children to reduce the sedentary behaviors, reducing TV watching and playing computer games, etc.

Throughout the book in each chapter there are FAQs. For example, one of the questions is "How can I encourage my son to be more physically active?" Such as thing like coming in and playing games, like hide and go seek and tag, just getting them moving. Again, do things together such as biking, hiking, skating. The other thing is involving children in family chores that get them doing things, such as raking, walking the dog, housework: they get to move and reduce their inactivity. Appropriate physical activity for children guidelines (from the Healthy Ppeople 2010), include 30 to 60 minutes of age and developmentally appropriate activity from a variety of physical activities on all or most days. Some should be in periods of lasting 10 to 15 minutes.

How do you counsel? The Bright Futures and Practice physical activity allows a wave counselling through the stages of change. We are talking about preparation, action, and maintenance and we will go through that a bit of how to incorporate that. For the precontemplation, we realize that this is when people are not aware. So the practical initialter's role is to make them aware of what is going on. To identify the benefits of physical activity, explain the benefits relevant to the patient it will help with blood pressure or whatever that the problem is, or weight. And it recommend that is the patient considers starting some activity. An example of counselling statements could be: "Hey, being more physically active is one of the most important things you can do both physically and mentally. Starting something is as easy as walking with your friends, it could help you maintain a more healthier weight and be more energetic."

The contemplateor is the one who thought about it and has not done anything. The preparation started, but is not really engrained in it. You can help him by identifying the benefits, how they feel after they did a little exercise. Help the patient choose an appropriate physical activity. Often people start too fast and get Injured and then they stop. And helping them overcome certain barriers and identifying the patient's confidence and making the change. Identify the benefits, also. For example, "What do you hope to gain from exercise?" And that gives the practitioner an idea of really how dedicated or committed they are to this. If the question is: "If you were active before, what did you enjoy and why did you stop?" That will help you identify some of the barriers that may be associated with the long-term success and exercise. You can help your patient choose appropriate physical activity. You can ask them, "What kinds of physical activities do you enjoy, and are there any activities you enjoyed in the past?" Again, "Do you participate in physical activities at school?"

You note as children get older there is less participation in school PE. So you have to go with that. What do you do with your family and friends? And that gives you an idea of what types of appropriate activities. Identifier barriers to physical activity. We talked about this a bit already, but you want to find out "Why did you quit before and what, you know, is your neighborhood safe for walking or jogging?" A lot of views in -- people in the United States live in unsafe neighborhoods and this is not a question that professionals ask, but we have to find out what is safe in the neighborhood, what is available, and find maybe some community resources that are available that will help the child be more active.

Again, evaluate the patient's confidence. "On a scale of one to five, how confident are you that you will start this physical activity plan?" If it's low -- 3 or below -- you may want to problem solve with the patient and family and revise the plan as needed.

The last two phases are the action and maintenance. This is when the person has been doing physical activity but it's not engrained in the routine, and maintenance is when it's been going for longer than six months. You praise the adolescent for being physically active and you help them remain by helping them identify social support, barriers, as well as assessing a confidence level of what they're doing. Praise would be: "I am really pleased that you started walking to school. I bet you feel more healthy and look, you lost 3 pounds since the last visit."

What also helps the family to remain physically active is with some preplanning: "I think it's great you're walking to school. But have you thought about what things you can do on the weekends, too?" Or, "Now, this is great you're working to school, but summer is coming. Have you thought about the things that you can do doing the summer that will keep you physically active?" And in helping the family as well as the adolescent identify social supports, such as: "You have friends that can walk with you, it's easier to do things with friends and helping them to identify friends that can do activities with them. What about your other family members? Are they helping you? What do your parents do that are physically active?" and looking at what support systems that they have for the family and the child.

Again, assessing the confidence level on a scale of one to five. If it's 3 or below, come up with an alternative plan. Also, the key especially for younger patients -- you have to counsel the parents. You want to review the plan of increased physical activity for the child and get the parents' guidance for providing this positive enforcement. Often parents only know how to provide negative reinforcement, but how can they present positively, how can they be a role model, how can they react with their kids and do physical activity? And also, provide healthy snack choices. Also, in this book, we had a lot of questions from parents such as: "What are characteristics of a good program, what are characteristics of a good coach?" What I put on this slide are what are the characteristics of an excellent coach. It's a checklist. And it's more in the books, but these are the highlights. The coach makes the sport or activity fun. If they work on teaching skills, and teaching new ones. They help the kid feel successful. They use positive style of interaction. They don't yell at the kids, curse at the kids, which what is a lot of coaches do, but they make it positive and they reduce the competitive stresses. There are physical activity resources. There are over 100 websites in the book that provide a lot of different community agencies as well as resources for the provider community.

In summary, health professionals are only one part of the country to help encourage adolescents. This book enhances the professional's opportunity to promote this message in a more developmentally appropriate fashion. Bright Futures and Practice also relates to disease specific recommendations for activity. What about asthma, what about eating disorders? And it reviews those and gives information in treating patients with these conditions. It also covers the strategy for the behavioral change counselling. It advocates the promotion of physical activity not only in a clinical setting but in schools and within communities, and allows the practitioner to become involved with community activities. Bright Futures is a user friendly resource that promotes assessment of physical activity, developmental approaches, and common problems related to physical activity. If you'd like more information, you can contact the National Center for Education at the address shown on the slide. Thank you.

Questions & Answers
moderated by Beth Zimmerman, MCH Information Resource Center

[Due to technical problems during the broadcast, two Q&A sessions took place at different times. Only the second is available in audio format. Both sessions are presented in the text version.]

>> BETH ZIMMERMAN: Van, we had a question on the website from Bill Cochran. He notes that a major issue when it comes to treatment as well as prevention of obesity is reimbursement. He notes that many insurance companies don't reimburse for services to address obesity, such as seeing a dietition. This makes it difficult for people to address this problem. He asks: Where do things stand as getting obesity acknowledged for a disease so people can get reimbursed for their efforts in dealing with this major public health issue?

>> VAN HUBBARD: I think we are making progress and having the medical community accept obesity as a disease. There are always stages that we have to go through. But with Medicare/Medicaid is now reconsidering having that as a designation; the recent IRS ruling, in which they are now accepting obesity as a disease, and treatment can be taken off as a tax deduction if you meet the other requirements, is an advancement in that area. We have to remember that just stipulating it as a disease does not automatically put it into the reimbursement category. That is a separate step.

>> BETH ZIMMERMAN: What about things like counselling for weight reduction and increased physical activity? How can providers bill for that?

>> VAN HUBBARD: Currently, in terms of -- it depends on what is in the insurance company's programs and what they agreed to with the different employers. The question is that some of the insurers are willing to include such benefits within their programs, but it will come at an increased cost. And so there is a trade-off there. And I think we all have to work towards trying to resolve this in the most economical way for all, in order to get it could be really covered.

>> BETH ZIMMERMAN: And I would imagine the EPSDT program under Medicaid, preventive healthcare for children would allow a vehicle for counselling with regard to overweight children?

>> VAN HUBBARD: Right. Again, CMS is currently looking at the question of how they are going to designate obesity within their classification.

>> BETH ZIMMERMAN: Okay.

>> VAN HUBBARD: And I believe that decision will be made shortly.

>> BETH ZIMMERMAN: We had another question posted from Mary Ann McGuckin in Akron. And I thank you for posting questions before the program. She focuses on the preschool children. She asks if there are any interventions for treating children with obesity, either working with the parents in groups or one on one interventions? Bonnie, do you have insight into that question?

>> BONNIE SPEAR: There is not a lot of research in the preschool. Most of the research comes with the school-aged child and above. There is quite a bit on behavior associated with eating and feeding, with temperament and all that, but I don't know that there is any outcome researched in the obesity area for the preschool child.

>> BETH ZIMMERMAN: Okay. What about broadening it a little more? She asks and I believe specific to preschool children, but we can think about it more broadly, about whether or not there are short physician office visit length treatment or prevention strategies that primary healthcare providers can engage in with their patients?

>> BONNIE SPEAR: Well, I think you're right. I think the research has showed that the parents of this age group of course control the total food and physical activity. And just a statement from the provider to get more active or to be appropriate physical activity can encourage families to be more active. It just adds to the other 4,000 guidances that physicians have 20 do in a short period of time. So it has to be able to be incorporated, maybe not by the physician but by the physician extender type of thing and their programs.

>> VAN HUBBARD: I'll make a quick addition. All the successful programs emphasized the family approach, what Bonnie implied in her comment. There are some new research investigations going on in the treatment of adults, in which they are trying to do some very simple procedures and see if that will work. And that is -- but that is a long way from getting to the child level.

>> BETH ZIMMERMAN: Okay. Great. Well, we talked here about the importance of families, we know that another major influence on children is schools. And we do have a question on the website asking about any environmental approaches that might have been successful in preventing obesity among children in school. In particular, they ask about if an environmental change, such as that related to the types of food that is available through vending machines in the school is made, for example, making more healthy snacks available through vending machines, versus candy and soda -- what strategies might be useful in getting such a change accepted by the school administrators?

>> BONNIE SPEAR: There has been some pretty interesting research done by Mary Story in Minnesota of looking at, in the vending machine, they put healthy snacks but then they reduced the price to under cut the unhealthy snacks.

>> BETH ZIMMERMAN: Oh.

>> BONNIE SPEAR: And these were well received, they actually sold out. But when they had to raise the prices to the actual cost, then students returned to the lower costs. I think basically we're thinking of cost. If you can convince administrators to raise the cost of the unhealthy snacks to offset the cost of the healthy snacks, that it tends to do well. But often the vending machines are paying for essential school functions, such as lights, janitorial services, so it's very difficult to convince an administrator that this will sell more or they can make this much money with that. But the groundwork is laid there that kids will buy it if it's priced right.

>> VAN HUBBARD: The other thing that we should emphasize is this is still in a research stage. Yes, they can look at some disappearance data of the different products in the machines at the different cost levels. To date, I'm not aware of data that actually correlates that with weight management or weight measurements in these children.

>> BONNIE SPEAR: You're correct. And I think just addressing environmental issues that we could address, whether it correlates to obesity, we have no clue.

>> BETH ZIMMERMAN: Okay. I'm going to go to a question that relates to a topic that you address in your presentation, Bonnie, and maybe you can just elaborate a bit on what you talk about in your presentation, since we are going out of order here. But in particular, in your presentation, you provided a lot of helpful guidance for clinicians who have the opportunity to meet one on one with children and parents to address the issue of weight loss. Can you highlight what some of those are first and then I'll ask a follow-up about more public health level activities that folks can do, since we know we have in our audience today a mixture of clinicians and public health officials.

>> BONNIE SPEAR: Okay. A couple of things. And basing this on the Bright Futures Physical Activity book, is the guidance is in the book about how much physical activity children at different ages need -- and what are developmentally appropriate. I think often what happens is parents push children too early into activities that are not developmentally appropriate. Kids are burned out or they are not capable of doing it. And they don't continue the activity. So I think making sure that activities that children are involved in are developmentally appropriate for the age and level of development and how to bring that into a primary care setting.

With that said, so much of physical activity is going to be outside the clinical setting. And kind of pushing the book a bit, there are so many references and resources available to families in this, how to get involved in different things. And even working on the book, I learned a lot of how, you know, about community activities. For instance, the Rails to Trails program. How communities can get federal dollars to help convert old railroad beds to walking trails -- and these are often in the lower economic communities and getting some resources available for kids to have safe access to appropriate physical activity. It also talks about, as in a public health or community level how you can get safe playgrounds and how appropriate things can be developed in that way. It also helps to set guidelines and policies. The other way this can be used, and we are using this a lot here, is the teachers are now using it to teach what is appropriate activity and guidance for that.

>> BETH ZIMMERMAN: The PE teachers are using it to identify what resources they should be doing?

>> BONNIE SPEAR: And using it as a reference guide in helping them teach the health class, which is where it's taught here.

>> BETH ZIMMERMAN: Operator. Are you standing by? I wonder if perhaps we could ask the telephone audience if they would like to participate as well in this conversation at this point and open it up for questions from them as well.

>> Hello, this is Rita Arnie from Missouri. We are having a question here related to the terminology that we use for children on the CDC website. I notice that it says very clearly that we should use the terms overweight -- sorry, at risk for overweight for kids who are between the 85th and 95th percentile. If they are above 95, that we should use the term overweight. But I keep hearing obesity referred to for children so much of the time. So I'd like for you to clear that up for me.

>> BETH ZIMMERMAN: Thank you. I think that's an excellent point and one, had we had the opportunity to hear Van's presentation first, we would have gotten a good definition. So, this is actually I think a really good way to bring up some of the topics that we would like to get at. Van, would you please talk about those different definitions of overweight and obesity in children.

>> VAN HUBBARD: No problem. Basically, she said it correctly. In dealing with children and adolescents, we do refer to the 85th up to the 95th percentile on the BMI growth charts issued in May of 2000 as "at risk for overweight";at 95 and above percentile, that is a category described as overweight for children and adolescents. There is no definition for obesity in children and adolescents. Part of that is because of the lack of tracking, although the tracking does get a higher level of probability as the child gets older, but there is a problem with tracking and there is also a problem with undue stigma being associated with being labeled as such. However, it's difficult to get people to stop talking about obesity, and I think we all would agree that at some level a person goes from overweight to obese even in childhood, and so we often -- we will use the term overweight and obesity. But in truth, obesity itself should not be used by itself in childhood.

>> BETH ZIMMERMAN: Thank you for that excellent question, Rita. Do you have a follow-up or is that a good answer for you?

>> No. That's fine. Thank you. I'm frustrated, because even today's agenda calls this childhood and adolescent obesity.

>> BETH ZIMMERMAN: I have to talk full responsibility for that. I apologize. That title was put into effect before we had our presentations put together and you're absolutely right. Thank you.

>> Okay. Thank you.

>> VAN HUBBARD: You'll notice in the Healthy People 2010, the objective does say overweight and obesity in the objective to reduce the prevalence of overweight and obesity in the country, as part of our goals. But, we -- from the federal side --when we use obesity, we always use it in combination with overweight.

>> Thank you very much.

>> BETH ZIMMERMAN: Thank you for asking the question. Another topic that you emphasized a lot, Van, in your prepared presentation, has to do with the importance of partnerships in addressing overweight and obesity in children. I was wondering if you could give some sense of what you talked about in your presentation, and also recommend any specific approaches you might share with our audience that have been successful in addressing overweight and obesity in children.

>> VAN HUBBARD: Okay. The issue of partnerships is that we need to all pull together in order to address, I mean, this as a public health problem. We also need to make modifications in the environment, at all levels. In the personal environment, home environment, work environment, school environment, community environment. All levels. And the only way that such modifications are going to take place is if there is a coalition of forces that come to bear on the problem. I often relate that the healthcare providers in the broadest sense should not only deal with the issue as they see patients in their practices, but they should go as a group to the schools, to the community's leaders, so that they can get across the message that there has to be an environmental change. At the school level, one of the things I think is very important -- and again it will need more than one group saying so -- and that is that we need to do more than just preach: Consume a healthful diet and get more physical activity.

In the school day-to-day, we show very little emphasis in terms of actual practice. In many schools, as the kids get older, the lunch periods go down in time or in some places it's been reported that they are even nonexistent. The physical activity has been removed from schools in many locations. There is decreased intramural sports, a decrease in varsity sports, and many of the activity periods were turned over to academic purposes. Therefore, we spend much of the school day in which the child may get some lip service paid to appropriate lifestyles, including good dietary practices, good physical activity practices, but they don't get the opportunity to actually do it in the school day. And if you think about it, much of that is also true in the workday for adults.

>> BETH ZIMMERMAN: I was just thinking that. Absolutely.

>> VAN HUBBARD: So that is one point where I think there has to be a coalition of folks that come together from different directions, but all agree that this is an important purpose to get together on and support. Because there is going to come with some increased costs to reinitiate some of the physical activity programs. And Bonnie may want to expand on that a bit more.

The other thing on partnerships that I want to get across is that different organizations are going to -- it would be beneficial for them to work together. This is beneficial in multiple ways in that it will help provide consistency of messages. It will help to be efficient in operations, in that many of the organizations go to the same experts for advice. They go to the same sources for funding of their individual projects. And often they basically, in some ways, reinvent the wheel each time, because they want to do their own thing. I think if by working together you don't have to reinvent the wheel, you can partner, you can build upon each other's doing it. Yes, you might lose some identity in doing that but overall, the ultimate product will be better. And so -- that's also what you need to do in terms of partnerships.

>> BETH ZIMMERMAN: Thank you. And with regard to your emphasis on schools and getting kids moving in schools, there is a question on the website from Carol Prentiss in Alaska. She says groups are talking about coordinated school health models. Is there evidence that schools implemented the CDC model coordinated school health program, and has it lowered the incidence of overweight and obesity? Bonnie, would that be something you could address?

>> BONNIE SPEAR: Yes. It would be very easy. I don't know. You know, I think that this may be something that we need to check -- that I'd be glad to check with CDC and post back at a later time. I mean, the school health guidelines I guess are about 3 or 4 years old now, so I don't know that we can show any outcome with that. But I don't even know how many schools are using this or even know about them. You know, with NASBE adopting them and helping with that, some of the physical activity programs may have been adopted. But I don't know as for the whole school model.

>> BETH ZIMMERMAN: Bonnie, do you know if there is research to show the validity and effectiveness of any weight management programs that work for children and/or adolescents?

>> BONNIE SPEAR: Yes. There is actually a few. Lynn Epstein has some validity studies and looking at it ten years old, the success of that. And primarily the success is to be based on diet, physical activity and parent interaction with that. And there are many programs, and I don't want to mention them, because I'm afraid I'll leave something out, that have validity and outcome studies that show that the programs are successful on a long-term basis.

>> BETH ZIMMERMAN: Thank you. Is there anyone in our telephone audience that would like to ask a question?

>> OPERATOR: I'm showing Ann Whiten Binner.

>> BETH ZIMMERMAN: Thank you. Go ahead.

>> I was wondering if there are any programs available for weight loss for children with special needs. Like the mylexmeningeocile population.

>> BONNIE SPEAR: That's an interesting question. Not that I know of. I know that there are residential facilities, like in the Prider-Willie programs. But I don't know -- I think some of the programs have been used with wheelchair bound children and using physical activity, using upper body types of things and getting the kids more active. But I'm not familiar of any program designed specifically for that. But that would be an interesting question to put out to other people.

>> Thank you.

>> BETH ZIMMERMAN: Another question from the website asks: Is this health issue, overweight and obesity in children, mirrored elsewhere in the world or is it just a problem in the United States? And I know that Renee Schwalberg, with the information and research center, may be able to address that question. Renee?

>> RENEE SCHWALBERG: I appreciate the opportunity to do a little early advertising for a project that we are working on with the Office of Data and Information Management at MCHB as well as the Division of Adolescent Health. We are putting together a data book, a chart book, on the findings of the international survey called the "Health Behavior and School Children Survey," which focuses on adolescents. And asks questions on a whole range of health issues. And it's self reported by adolescents themselves in school. And we have several findings measures in the area of physical fitness and nutrition. We don't -- the survey did not specifically ask students as far as I remember to report their height and weight. So we are not reporting specifically on overweight. But, we have several indicators of children's activity level and diets for children in about 30 countries, mostly in Europe as well as Israel and Canada and the United States. And I'm just looking at some of the numbers now.

It's interesting, the United States seems to fall about in the middle for a lot -- for the physical activity and nutrition measures. Students who report exercising twice a week or more, for example, the countries in the lead are Northern Ireland and Austria and Germany and the United States is somewhere down around the middle of the pack, maybe the bottom third, with about 54 percent of girls and about 75 percent of boys exercising twice a week or more. Students who report watching television four hours or more a day: the leading countries are actually Lithuania and Slovakia, with the United States down in the bottom third. Students, on the diet side, students who report eating fruit: the leader country is Portugal, where nearly everyone eats fruit every day, but the US is in the bottom third, about half or more between girls and boys.

>> BETH ZIMMERMAN: Can we get that in writing?

>> RENEE SCHWALBERG: The report, I don't want to give a definite date, but the chart book should be out I think in the next six months or so.

>> BETH ZIMMERMAN: Wonderful. And we can send an e-mail to the folks who have registered for today's program to let them know about that.

>> RENEE SCHWALBERG: We will send e-mails to everyone whose name we have got.

>> BETH ZIMMERMAN: I appreciate both of our presenters doing their presentations for us, preparing them, and being very flexible today with their timing. I'd like to close the program just with a brief opportunity for folks on the telephone to ask any questions that they may have about Dr. Hubbard's presentation?

>> Hi, this is Bill Cochran. Van, I enjoyed your presentation. I thought this was helpful. My one comment of "who should be involved?" -- the one group you had missing there, which should be highlighted is government. Government is involved, you're here doing this for us. But, as you know, many states do not require their schools to have physical activity in school. And I think, you know, to try and increase the probability of this occurring, I think indeed we need to get the state governments behind this as well as the national government in encouraging and promoting exercise and other nutritional education in schools.

>> VAN HUBBARD: I would agree. There is a role for government in this. As I was trying to emphasize from our level, we always put on these types of programs in which we talk about the problem and the biggest question that we get, and the most frequent question that we get, is what more are we going to do as a federal government? And there is a limit to what we can do as a federal government and we need to call upon others to also play their part in working towards our ultimate goals of health. Government does have its participatation in many of the activities I described.

>> I agree. It also goes along with the first question you answered for me earlier in the program in terms of reimbursement, that we have to get HCFA to acknowledge this as an entity.

>> VAN HUBBARD: That is now CMS. As I said, they are discussing making that change. However, even if that change does occur, it does not automatically mean reimbursement.

>> Correct. Thank you, Van.

>> BETH ZIMMERMAN: Thanks very much, Bill. I appreciate you raising these issues. Well, I'd like to thank everybody for your participation in this program. I do apologize for the departure from the agenda, but we did fulfill our motion. So thank you again. Again, the archive will be up for folks who come back to. You can refer your friends to that. And we look forward to having you with us again for the June program. The audio conference is now officially adjourned.