University Times

Increasingly, studies have shown, people are seeking health-related information. A recent Pew Internet study found that 80 percent of Americans with Internet access turn to the web for answers to their medical and health questions.

But three-quarters of consumers fail to check how reliable and how current that information is, the study revealed.

In an effort to detangle some of the overload of health information that is out there, this occasional University Times series, On Health, is turning to Pitt experts for current — and reliable — information on some of today’s major health-related topics.

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Obesity has reached epidemic proportions in America. But the prevalence of obesity at younger and younger ages forebodes a particularly ominous future: For the first time in America’s history, today’s children could face shorter, less healthy lives than their parents.

According to the Centers for Disease Control and Prevention (CDC), obesity rates have increased four-fold among children in the past 40 years, due in part to less physical activity combined with increased consumption of high-calorie foods and drinks.

The current numbers and their implications are staggering.

A recent study based on data from the 2007-2008 National Health and Nutrition Examination Survey found that 9.5 percent of infants and toddlers were obese.

For ages 2-19, 31.7 percent were overweight and 16.9 percent were obese. Translated into numbers, that equates to more than 23 million children and teens.

Because children are growing and girls differ from boys in amounts of body fat, obesity in children is defined in terms of a body mass index (BMI) that also takes into account age and gender. Those at or above the 85th percentile on CDC growth charts for their age and sex are considered overweight; those at or above the 95th percentile are obese.

Researchers found 7 in 10 obese children (ages 5-17) have at least one risk factor for cardiovascular disease and nearly 4 in 10 have two or more risk factors. Obese children are at higher risk for high blood pressure, high cholesterol and type 2 diabetes. Other health conditions associated with being overweight include asthma, sleep apnea and fatty liver disease.

What’s more, obese children frequently grow into obese adults, placing them at higher risk for additional health problems including cancers, stroke and osteoarthritis.

The cost of obesity goes beyond its impact on quality of life. The 2009 America’s Health Rankings report projects that in 2018 annual obesity-related spending will rise to more than $343 billion due to the more than 42 percent of Americans who will be obese.

A security risk

In addition to increased health care costs, a recent report to Congress by a group of retired military leaders warns that obesity among young people not only is a threat to their health but also has implications for national security.

The report “Too Fat to Fight,” released earlier this year, warns that being overweight or obese has become the leading medical cause that disqualifies recruits from military service.

The report cites CDC statistics that found at least 9 million 17- 24 year olds — 27 percent of that age group — simply are too fat to serve in the military. In addition, it notes that over the course of a decade the number of states with 40 percent of young adults considered to be overweight or obese has risen from one to 39. In Kentucky, Alabama and Mississippi, the numbers were even higher: More than half the young adults in those three states qualified as overweight or obese.

“Obesity rates among children and young adults have increased so dramatically that they threaten not only the overall health of America but also the future strength of our military,” the report stated.

“What needs to happen in the schools is relatively straightforward: Take the junk food out of schools, improve the meals served, provide healthier meals to more kids, and offer programs that encourage kids to eat better and exercise more,” it concluded.

Slim hope

While obesity rates continue to rise, there is some hope for the future: CDC statistics show that obesity among children is slowing. Between 1999-2000 and 2007-08, obesity in school-age children rose from 16 percent to 17 percent.

One year doesn’t make a trend, said Department of Psychiatry faculty member Linda Ewing, who is among a number of obesity researchers at Pitt. “We’re not celebrating yet.”

Late to the gate

The obesity epidemic has a solid head start on efforts to combat it. Ewing said when her research group began to look at the issue of childhood obesity in the late 1990s, it was difficult to generate much interest, recalling there were few concerns being expressed either in popular media or among pediatricians. “If nobody’s telling you it’s a problem, it’s hard to believe it’s a problem,” she said. In addition, there was little point in identifying patients when doctors didn’t know exactly how to treat them.

“The problem already was very well established in children before people started to get serious about it,” Ewing said.

Why we’re fat

Obesity is highly hereditary but the condition also is strongly influenced by one’s environment, Ewing said, noting that a complex mix of environmental, cultural, societal and family changes in recent decades has contributed to the nation’s weight problem.

Some neighborhoods are dangerous, hindering children’s ability to be active outside without adult supervision. Inexpensive food in oversized portions is readily available. Busy, stressful lifestyles also contribute. Tired parents often find it easier at the end of the workday to order takeout, grab fast food or dine out in restaurants where it’s more difficult to assess the calorie content or nutritional value of the meal, she said.

With so many complicated pieces coming together to add to the problem, “any change would make an impact,” Ewing said.

“We’ve set up an environment that makes it harder than it should be,” she said. “It’s not easy walking past McDonald’s and the irresistible smell of French fries. It’s human nature to succumb to it,” she said, pondering, “What if vendors on the street sold fruit, whole-grain breads and healthy vegetables?”

Admittedly, “What’s built up over the past 30-50 years is not going to be undone overnight,” she said. Still, change is necessary.

“Everyone knows the ingredients of what has to happen. It’s not a mystery.”

Difficult changes

Maintaining weight is a relatively simple equation of balancing energy taken in with energy expended, but not so simple in practice, as anyone who’s tried to lose weight likely knows.

“Obesity in children or adults is an incredibly difficult challenge,” Ewing said. “We are hardwired to defend our weight,” she said, noting that at the most primitive level, fat reserves are necessary for survival and weight loss triggers complex physiological responses.

However, in the context of our current environment, Americans have little risk of starvation, and a car-oriented culture makes maintaining physical activity more difficult. “Conveniences cause us to burn fewer calories,” she said. “We don’t have to walk 10 feet and we can purchase food on every corner,” she said, adding that what’s easily available tends to be high in fat and calories and low in nutritional content.

High profile campaigns

First Lady Michelle Obama has put the issue of childhood obesity into the public eye through her Let’s Move! initiative that aims to help kids become more active and choose healthier foods. A related organization, the Partnership for a Healthier America, targets areas for action that will help meet the goal of curbing childhood obesity within a generation. The Robert Wood Johnson Foundation also has taken up the issue, having directed millions of dollars in recent years to support endeavors that aim to curb childhood obesity.

The multi-agency White House Task Force on Childhood Obesity earlier this year released a report that targets information for parents, healthier foods and increased physical activity among the areas for action against the obesity epidemic. (The report can be found at www.letsmove.gov/pdf/TaskForce_on_Childhood_Obesity_May2010_FullReport.pdf.)

In light of the increased attention on fighting obesity, a broad range of initiatives already are underway in pursuit of healthier lifestyles for children. Among them:

• The National Football League and the American Heart Association are partnering in the NFL Play 60 Challenge, which aims to have kids commit to at least 60 minutes of physical activity each day.

• Food manufacturers Campbell Soup, Coca-Cola, General Mills, Kellogg, Kraft Foods and PepsiCo have formed the Healthy Weight Commitment Foundation, which intends to cut calories, reduce portion sizes and introduce healthier food options in their products. Combined, the six companies manufacture about 20-25 percent of the food consumed in the United States.

• Qubo, which provides children’s TV and online entertainment programming, accepts food advertising only from companies that meet nutritional guidelines developed in conjunction with Pitt pediatrics faculty member Goutham Rao, clinical director of the Weight Management and Wellness Center at Children’s Hospital.

Ewing noted that increased public awareness has brought a flurry of activity, ranging from ambitious efforts to research and correct elements in the environment that hinder physical activity, to neighborhood-level initiatives such as encouraging scout leaders and others to cut out snacks or offer healthier ones at their meetings.

Small efforts, such as encouraging schools to limit classroom birthday celebrations to one day a month for all birthdays in that month, or limit acceptable treats to healthier options, are steps in the right direction, she said.

“All pooled together, these things are making a difference,” Ewing said, noting that while major research efforts are making strides, the smaller initiatives contribute as well.

Treatment

The Children’s Hospital Weight Management and Wellness Center, which is marking its sixth anniversary this month, draws patients come from across western Pennsylvania and beyond to its clinic in Oakland and satellites in the South Hills, North Hills, Monroeville and Johnstown.

The center accepts patients ages 2-19 through primary care referrals. The average patient is 11 years old, stands about 4 feet 10 inches and weighs 150-160 pounds, Rao said.

The clinic setting enables the center to serve a large volume of patients — 3,000 since its inception — even though individual weight management counseling is time consuming. Unlike smoking, which is a singular behavior: “You buy the cigarettes, you smoke, you suffer the effects,” Rao said, obesity is a complex issue influenced by a person’s appetite control and food choices as well as by the environment — including physical activity levels and other factors such as what friends or family members eat. “It’s not as simple as ‘Stop this, or this or this.’”

Developing healthy habits

Improving eating habits is the more important half of the equation, but finding ways to incorporate physical activity into the daily routine is needed as well. “We recommend habitual physical activity that you don’t have to think about,” such as daily walking, biking or playtime over organized team sports, Rao said. Obese kids may be part of the soccer team, but they tend not to be as actively involved as their teammates.

Although the center’s treatment tracks vary, the typical course consists of monthly visits for a year, then reassessment. The focus is on changing habits rather than on diets, medications or surgery, Rao said. As complicated as the causes may be, “obesity is just a manifestation of behavior,” he said. “They’ve taken in too much energy and expended too little.”

Patients receive an initial medical evaluation then consult with a wellness adviser, a registered dietitian who collaborates on setting goals for achieving lifestyle changes. Goals are set with the parents of patients age 6 and under, or directly with teenage patients. For kids in between, negotiations are undertaken as a partnership with the parents and the child. The wellness advisers seek agreements from patients to change certain behaviors and keep taking the changes up a notch over time.

Attention is individualized, with wellness advisers taking time to talk with new patients about their eating habits and activities, to discuss what weight-loss strategies have been tried and to talk about how patients feel and what they want to accomplish. The focus is more on being healthier as opposed to losing weight.

Behavioral goals are set with an eye toward making changes that will have the most impact. “It’s never ‘You need to lose five pounds before I see you again,’” Rao said, adding that because children are growing, measuring progress in terms of maintaining or reducing body mass index (BMI) is preferable to tracking a patient’s actual weight. By that measure, some 69 percent of the center’s patients are making progress, he noted.

Clinic clientele

The families who visit the clinic vary. Some come simply to placate the PCP who referred them.

Others are looking for an underlying medical cause, Rao said, adding that although the center performs some routine testing, medical issues rarely are the reason children are overweight.

“These are huge issues for us,” he said. “Some think it’s a genetic issue and that it’s inevitable and nothing can be done — they’re just going to be overweight.” While some individuals may be at higher risk for obesity, it’s not inevitable, he said.

Some parents acknowledge that their child eats too much or makes poor food or drink choices, while others come to the center knowing what to do, but needing support to stay on track.

About one in every five or six clinic patients chooses not to make changes. “We say, ‘These things are what you need to do.’ If the answer is no, then there’s not much we can do for them,” Rao said.

Nutrition knowledge

Some patients lack an understanding of good nutrition and basics such as what constitutes a healthful serving of food. Rao commended New York City for requiring that nutrition information be posted prominently in chain restaurants. “Some people will react with ‘It has 1,500 calories and I’m going to eat it anyway,’” he said. “But you’ve got some people who have no clue.”

It’s understandable how it’s easy to be confused, Rao acknowledged. “Food companies are not totally forthcoming about serving size,” he said; moreover, serving sizes shown on food labels can be inconsistent. “For example, a 20-ounce bottle of soda is 2.5 servings,” he said. But a 12-ounce can of soda is labeled as one serving. “Which one is it?” he asked.

In the clinic, wellness advisers educate patients about what a healthful, balanced meal looks like. A picture of a plate divided into quarters and filled one-half with vegetables, one-fourth with meat and one-fourth with a starch provides a visual point of reference.

The advisers also can print out individualized material on a broad range of topics including snacking, mindful eating, getting active or dealing with bullying.

Online support is available as well. The healthy behaviors for life web page (http://hb4life.com), developed in part by Rao, offers tips and tools on nutrition, activity and other aspects of healthy living, with separate sections for children, teens and parents.

Rao also is researching incentives that could boost kids’ motivation in a cost-effective way. In a trial comparing the success of in-person versus online support, some of the research subjects are eligible to earn a gift card worth as much as $230. The incentive credits them $1 per day if they log into their online account. Those who miss one day can do so without penalty, but two consecutive missed days cost them 20 percent of their account balance.

The six-month trial wraps up later this year. “I hope it shows something really dramatic,” Rao said, noting that if kids can successfully achieve a healthy weight through a program in which costs total less than $500 per person, it’s a bargain.

Prevention

Ewing said, “Prevention is where it also has to start,” admitting that side of the solution needs work. “With kids, if we can identify early enough that they’re not on a good trajectory and we can stop that,” it will be a huge step in the right direction.

“The first foods that are introduced to a child are incredibly important,” Ewing said.

“There is significant agreement that intervening with parents is the most useful way to go” to ward off weight problems in young children by fostering healthier habits early. Choosing healthier snacks, having meals together and getting active by biking, walking, sledding or playing ball together benefits the whole family.

If children are accustomed to finding ice cream, pizza, cookies and whole milk in the kitchen every day, switching to healthier options later on can be hard.

“Changing that behavior requires quite a few steps,” Ewing said. Keeping the food out of the house in the first place, finding a palatable alternative and repeating the healthier habit consistently is complicated. “All of that is not so easy to do,” she acknowledged.

But it’s not impossible, she said.

“The younger we form healthier habits, the better off and easier it is,” she said.

Simple tools aid understanding about the varying amounts of calories and nutrient value of food. The Go, Slow and Whoa foods approach promoted by the National Heart, Blood and Lung Institute categorizes low-fat or low-sugar foods such as fruits and vegetables, lean meats, low-fat dairy products and whole grains as “go” foods that can be eaten anytime. Foods higher in sugar, fat or calories foods are “slow” foods to be eaten less often. “Whoa” foods — to be eaten only in small portions and on special occasions — are highest in sugar, fat and calories.

The “stoplight diet” system developed by former Pitt psychology department faculty member Leonard H. Epstein is similar, using the colors on a traffic signal to categorize foods into using green for healthy “go” foods, yellow for foods to be eaten with caution and red for fatty, sugary foods that one should stop and think about before eating.

Starting at home

Part of Ewing’s research includes the Health for Families program, which targets lower-income families who have an obese child. Families were identified in pediatricians’ offices for this research, conducted in partnership with the UPMC Health Plan and the state Department of Public Welfare. Researchers talk with parents in person and by phone about making good food choices, eliminating soda pop and other high calorie/low nutrition food from kids’ diets and increasing activity.

Participants receive newsletters with information on active community events, walking DVDs to support indoor exercise and monthly packages that include ingredients for a healthy “recipe of the month” to try.

Because the intervention is done largely by phone, it someday could be offered more widely through pediatricians’ offices, Ewing said. “That’s the goal: To get something into the primary care offices that we can hand over to the staff and to the nurses and the physicians there to help families to deal with this problem — bringing something that’s evidence based, accessible to families and easily deliverable in a location where families are seen frequently in the first decade of life.”

Support for families

Rao also is a strong advocate for widespread education on healthy living. “No matter how many patients we’re going to see [in the clinic], we’re not going to solve the problem,” Rao said.

Schools and doctors’ offices are areas where strides against obesity can be made, Rao agreed. “The way I see things playing out, people who are community based — teachers, doctors — will be playing a bigger role,” he said.

Because young children typically have regular doctor visits, PCPs can reach almost every obese child, Rao said. An online course has been developed to train doctors in discussing healthy weight with their patients, with prescription pads customized for setting nutrition and activity goals.

Creating a healthy school food environment also is important.

Children spend six-eight hours a day at school and often receive meals there, Ewing noted. She said changing the foods available in the lunchroom and building more physical activity into the school day has an impact.

Rao said school personnel and students need better nutrition information. “What I’d really like to see is school-based curriculum so children become more aware.” Children naturally want to share what they’ve learned when they get home. “If they know, they may go home and tell their parents, ‘You shouldn’t buy all this soda for me,’” he said.

He sees a knowledge gap in many families at the weight management clinic. “Sometimes there’s a motivation gap as well, but we’ve got to overcome the knowledge gap first.”

There are no quick fixes, Rao said. “It took us 50 years to supersize our culture. It won’t be reversed overnight.”

—Kimberly K. Barlow