Exercise Journal Club: Pediatric Obesity 2017

And now we're going to move on to the newest member of our Strong for Life team, Jody Dimanta. She's been with us for about a year now, and she came, came all the way from New York. She's really believes that exercise is medicine and has really been working her whole career with special populations. um, talking about developing exercise education and curriculum for our patients, but also really believing in the importance of just being active and how that keeps you healthy. And Jody has a couple of, um, talks to go through with us. So thanks, Jody. Of course, um. Hello, everybody. I chose this article because um summer activity is something that I actually focus on a lot with our patients. Um, I actually had the conversation about 3 times yesterday because we're to the point down here, summer starts so early for these kids that If we're not gonna see them for 3 months, we're already at summer vacation. Um, but I'll talk more at the end of the presentation about how I try to work some of, um, these methods into my clinic visits. Um, so basically, the authors just wanted to look at obesity prevalence, um, growth during the school year versus during the summer. Um, so some studies had been done previously looking at the same subject, and they saw the same thing, growths in obesity during the summers, but the authors of this article had a little bit of doubt about the sample sizes that had been used previously. One just did a local convenience sample. Another study did nationally represent. sample. however, they only followed for one summer, and it was actually kindergartners in 1998. So needless to say, a lot has changed in behaviors from kids back in 19998 versus kids today. So basically we were looking at two things. They wanted to estimate whether overweight and obesity prevalence grows faster during the school year or during summer vacation, and they wanted to assess the relative importance of school and non-school risk factors in relation to childhood obesity. Um, so the school risk factors included school meals, competitive foods, phys ed, and school environment. For anyone not familiar with the term, the term competitive foods, because I wasn't, um, it comes from the state of California, and basically they define it as Any food that is sold in during school hours on the campus that cannot be reimbursed through the federal food program, so I think if you know the cheerleading team has a bake sale at school, that would be considered an example of a competitive food. And then non-school risk factors we're looking at screen time, child directed food marketing, lack of summer school programs and camps, and lack of nutritional education to the families. Um, some methods, uh, the authors actually pulled from the early childhood longitudinal study, um, which is a Study that was done. It consisted of 18,170 children in 970 schools and 90 sampling units, but basically once they broke it down and excluded children with missing covariants and children from year-round schools because they have shorter summer vacations, then the sample size for this study was decreased to 13,0006 children from 846 schools. As far as the sampling units go, they either did uh large counties or they did smaller counties that had similar demographics. Um, so children's height and weights were measured each fall and spring, so basically a total of 6 occasions. Fall measurements were taken 5 to 7 weeks after the first day of school. Spring measurements were taken 8 weeks before the last day of school. Um, and on this occasions, all the measurements were taken twice. Um, as far as the stats go, a multi-level growth model was used to estimate growth in mean BMI, uh, overweight prevalence, and obesity prevalence during each summer and each school year. They estimated mean growth rates, variation of growth rates between children in schools, and association of growth rates with demographic covariates. Those covariates included gender, race, ethnicity, age at the start of kindergarten. They looked at the family income, mother's educational level, indicators for employment of the parents, and whether the children lived in a single family home. So when we look at our chart here, we can see prevalence of obesity increased from 8.9% to 11.5%. Prevalence of overweight went from 23.3% to 28.7%, and the mean BMI grows in every period. However, it was growing faster during the summers than during the school years. So basically the results were all increases in obesity and overweight prevalences occurred during the two summer vacations and no increases occurred during any of the three school years. At the start of kindergarten, the prevalence of overweight was approximately 23%, and obesity prevalence was approximately 9%. Um, during summer 1 and summer 2, both overweight and obesity prevalences increased by approximately 1% point per month. Um. These were obviously pretty significant increases which over the basically 2.6 to 2.7 months of the average summer vacation added up to a 2 to 3% rise in overweight and obesity points. Like I stated earlier, during the school year, we didn't see any rise, and we actually saw a decrease during the kindergarten and second grade years. Um, but even still, these kind of, um, Little decreases we saw, and then the stability we saw during the school year still wasn't enough to basically undo what was done during the summer vacations. Um. So at the end of the day, the standard deviation of the BMI growth is approximately 3 times greater during the 2 summers than during the 3 school years. Which leads us to believe that The major risk factors for childhood obesity are lying outside of the schools, and that what's going on during the school years may actually reduce the risk of overweight prevalence from increasing during the school year. Um, So what behavioral changes explain the acceleration of BMI growth during the summer? It's unclear as far as food consumption goes what goes on with these kids during the summer, but it has been found that children tend to sleep less. And they watch more screen time. Um, Climate obviously plays a big role, um, down here. It's a challenge, you know, it is boiling during the summer where up north, the kids might want to be outside more and maybe be willing to go outside more. Um, but basically, it's, it's hard to say that these behaviors necessarily led to the increases over the summer because the study didn't look at the behaviors of the kids. It just looked at the prevalence of obesity and overweight. Um They looked at some school-based interventions where they tried to carry things over into the summer for these families, but there really just wasn't any positive effect. They tried to get the parents involved and kind of teach them things that they would hope to kind of follow through with outside of the school, but just didn't happen. And then there are other out of school programs that really just are underexploited, such as summer camps, summer learning problems, um, parent nutrition education, parents trying to reduce screen time in kids, um, and also reductions in child-directed food marketing. Um, which kind of brings me back to where I was at the beginning. Uh, what do I do? How do I try to combat this problem with our families? Um, so something that I've done is I will take the kids' schedule, I'll look at PE class, I'll look at recess, I'll look at any extracurriculars. Um, it might be an after school program where I know the kids are being active for 30 minutes. Uh, maybe it's a sports program. Um, and I have the parents add up the number of minutes that their child is active because of structured school programming, um, and I make them look at the number and you know, some kids it might be as little as 100 minutes a week, other kids it's as much as 500 minutes a week, and the parents are usually pretty surprised at. Numbers, um, they don't necessarily realize how much they're the little kids are moving throughout the course of the day. Um, obviously it's not the same case in middle and high schoolers where PE and tests really aren't a thing anymore, um, but focusing on the little ones, the parents are always pretty surprised by their activity levels. Um, we'll always look at accessibility. Um, is the child gonna go to summer camp? Is there a pool available? Um, we offer YMCA scholarships, so kind of giving parents that option, uh, just trying to figure out what they have. Assist you to help them come up with a plan. Um, caretaking is a huge one, you know, we've had families who parents don't want the kids outside during the days while mom's at work because maybe the older brother is caring for the younger, um. There's been instances where the nanny, you know, doesn't like to go outside, so we focus a lot then on indoor activity. Um, I might hate tablets, but kids are going to use them, so why not use them to be active. So we'll talk about all the active apps there are for children. Um, a lot of times I'll talk about PBS. The station has a website called Zoom that's dedicated 100% to kids being active, tons of different games. Is that the parents can just print directions and have it there for the kids. Um, we'll talk about good old fashioned games where you don't need electronics, um, something as silly as blowing up a balloon and, you know, hitting it around the home, um, scavenger hunts, uh, helping with chores, um, anything to just get the kid up and moving versus sitting for hours at a time, you know, watching TV or on the tablet during the summer hours, um. And that kind of all just goes together with, you know, identifying the big barriers these families have and trying to help them work through it and kind of the further out from the barrier we can work, the odds are of them being more successful once the summer comes, which is why I start so early with the families. Even right now if I know I'm going to. See them back at the end of April early May, where I know we can talk about it, then I'll say, you know, start planning, start thinking, you know, are you going to be working are the kids going to be around that way at the next visit it's not like hitting a brick wall. It'll have given the family and the kids time to think about it and time to plan a little bit. Um, so at this point, if anybody has any questions, I'd be more than happy to answer. Thanks, Jody. That was great. I think. You know, I know when I talk to families in clinic, it's like the summer is really good or really bad, right? It doesn't sort of one way or the other, it tends to go. But I think it's really important to really think about how far in advance you have to start planning, right, because you think about it now, you know, people who have means to do camps are signing up for camps already for the summer. People without are looking for other options, but the sooner we start talking about it, the better. What, what's been your experience, Chris, with summertime and Parents and activities. Yeah, and I just find activity in general is always so individual, it's so not one size fits all. It really takes some time to find out what's gonna work, what they like to do, when they like to do it, what time they have, and really constantly evaluating it. So yeah, I just, I find that advanced planning makes a difference and really being willing to kinda move around and, and, and find what's working for them at that particular time. It's very individual. Yeah, absolutely. And that's just in general, right? It's not even the summer. I mean, going through these kids' schedules, it's, yeah, some of them don't get home till 78 p.m. each night. Um, those things are out of their control, right? But trying to focus on the things that are in their control and, you know, trying to promote change there is really all I can do. Do you change the message depending on the time of year then? Um, I mean, not really. I, I think the message is always just, you know, move. Um, there are times where kids might, the younger ones are easy. I know that they're gonna have PE and recess for a majority of the school year. Um, I think the older ones. This is when we kind of run into more sedentary time. Um, so we might, you know, down here with the weather and the allergies and this and that, um, I might kind of change the message depending on what the biggest barriers seem to be for everyone at that time. Uh, but the main idea and the point I just try to drive home to parents is, you know, it doesn't have to be this kind of stressful production to kind of try to get your kid. I mean, I think some parents feel like So you're telling me I have to take them to a park for 1 hour every day, and it's like, no, you just need to get them to move for 1 hour every day. So yeah, it's intense activity is important, of course, but what's more important is making sure that they're not spending 4 hours on the couch after school, you know, I. to Mom, if you cook dinner, have, you know, little Susie be your sous chef. Can she be in the kitchen grabbing ingredients for you? Or can somebody, you know, get the clothes out of the laundry and bring them upstairs? Sometimes just trying to get the families to focus more on movement, um, I think it takes a little bit of the stress off of them, and it kind of comes more naturally at that point. John, what about you? Any thoughts or comments? We, I do a lot of work in schools through our Choosing Healthy and Active Lifestyles for Kids program, and this, this article really highlights one of our biggest problems is we, we can control the kids during when, when they're at school. We know that a lot of our kids will eat most of their meals at school, breakfast and lunch. Um, during the school year, and we can increase their physical activity, and we've shown that in the, during the school year, but we really do not have great control during the summer and, uh, we haven't figured out quite how to translate, keep that activity going from the school year into the, into the summer. Um, and I think that certainly that's something we're, we're working on now, but I, but I think it is a major challenge. Mhm. It is, yes. And I, and I love your comments about the weather. We've actually had clinic days where people have come in and told us it was too hot and other families tell us it was too cold. So I don't think we should underestimate the importance of weather and physical activity. Uh, Tory, any thoughts about what goes on in Maine or programs that have worked for you? Yeah, well, we know weather up here, that's for sure. Um, so, um, you know, it's a challenge. I mean, it's our biggest, we've been following behaviors for Maine kids over the last 10 years and physical activity is the one that really isn't changing as much as we'd like. So we're very concerned about it. We're sort of, uh, hitting it from all different aspects and, you know, John, you're right, we're, we're doing an OK job in, in the schools and so our, our focus, some of our focus is gonna be the out of school time. And that's working with our YMCAs who're doing fantastic work, our Boys and Girls Club, the rec departments, uh, summer camps. We have a lot of camps in Maine here, so working with them to incorporate the 5210 message into all of those programming. Um, we're also gonna be, we'll be doing a lot of listening to parents. Parents are pretty overwhelmed with, um. With life these days, so trying, you know, as Jody said, trying to do little things, trying to make sure they, that we're not saying that your kids have to run 10 ks, just getting up and movement. We found, uh, and so we're, we're also doing some, um, advertising to teens, which is gonna be really exciting this year. We're starting an advertising campaign, um, focusing on the teens and the, the dialogue that goes on in the teen's head about should you exercise, should you not. So we're trying to hit it from a lot of different, uh, different aspects. Wow, that's great. Yeah, teens are their own special group, right? Yeah, and the younger ones. Claudia, to me, I think this is really an area where public policy can play a role, at least in the state of Minnesota, the requirements for gym class, um, is 1 year. So 1 year out of 4 of high school, you have a gym and and Actually, that's only half of the year. The other half is health, and the rest of you aren't required to have gym class. And I feel like that's such a missed opportunity. These kids are captive 8 hours a day, Monday through Friday, and we know the correlation between physical activity and academic success. It seems like it behooves the kids, it behooves the schools to help their kids be more active. So I don't know where Kelly Brownell is, but getting, um, schools to pay attention to the physical activity opportunity would be helpful, I think. Yeah, I mean that's the same in Georgia too with the high school students, um, and even the younger ones, I mean, rarely recess is used as punishment, right? It's, how do you get recess? Well, we haven't in weeks because we have the bad class and be insane, um, but then I applaud the teachers. I mean, we had one. Um, patient who their school, they have to do every half hour brain breaks where I'm not sure if you're familiar with the website GoNoodle, um, but it's basically little short videos where the kids get up and they can do dancing or whatever it is with the other kids on the screen, um, so it makes me so happy when I hear about teachers implementing that, but I mean it, it's probably only a handful of our kids that get to experience that. And Alan, you had some questions. Do you wanna go ahead and discuss those? I find this article, you know, ironic since the schools have taken such a rap and the food in the school takes such a rap. But anyway, the article says what the article says. One question that comes up, I had one mother who pointed out to me that her son gained weight during the summer because he came off his ADH meds, ADHD meds. Did they control for medication changes at all? Um, that I do not know. Um, they just pulled from that, what is it, the ECLS, um, so they didn't list it in any of our covariates or what they kind of look through, um, but I'm sure if you go there's a whole website for that, um, national study that you can go and, and see if they did. And certainly the food environment in the school versus the food environment when they're out of school during the summer is way different. So that's an interesting one to try to dice out, yeah, and I think the authors, you know, realized that, and they said we don't know what goes on. And unfortunately the sample that they pulled from didn't look at those things either. They didn't look at behaviors, they just looked at the numbers. And then my third question, I'm just asking you, I'm ignorant. Has anybody done any accelerometer studies in kids during school versus kids during the summer, for say a week of school versus a week of summer or anything like that? Um, I do not know. Um, Dr. Walsh is, do you know? I'm not sure if those have been. I haven't, I haven't seen one. I don't know what's been done, but we can, we'll look for it and maybe send it an email afterwards. Be an interesting study. Yeah, yeah. I wanted to piggyback off of Alan's comments about the medication and the food because I think We have so many parents that will come and tell us we're giving our kids a break from their ADHD meds, whether that's over the holiday or um during the summer vacation, and I'm just, I just wanted to put that out there to the pediatricians. On the um panel, kind of what your opinion is of that because that's also when we see a lot of not only just weight gain, but just trying to get the kids to follow any directions or stay focused and work on their goals becomes incredibly challenging at those times. um, so I was just kind of curious what, what. The opinions are out there of that idea of taking a break. Well, there's a significant correlation between obesity and ADHD, and it's um proposed that one of the common um underlying pathways that contributes to both is decreased dopamine activity. And so, uh the stimulants act to increase that dopamine activity. Um, so if you're gonna take a break from your stimulant medication, you are gonna be in a position where you're seeking more input, and it might be input from food, it might be input from other stimuli around your environment. So for me in, in doing weight management, I'd say, Every day, take your stimulant, no breaks at all. Every weekend day, every summer day, every single day, because it's going to help you with functioning in every realm of your life. Well, there's also other medications like beta blockers, antihistamines that we know aggravate obesity. And is there a difference in the medication pattern of some sort that nobody has recognized? Now, being a um full-time pediatrician, I will say that there are a lot of times there there are kids that um I do, you know, kids who are, who are not gaining weight well, who have to, have to be, who really struggling to get to maintain weight when they're on ADHD meds, but I will have them take breaks from it. I mean, I think there are, it's, it's very situational, and you definitely have some kids that need to come off of it who are having side effects, who you're just trying to. Get through the school year as best you can. But I absolutely agree too that like there are a lot of kids that their ADHD, their, their big manifestation is impulsivity, and sometimes there's nothing more impulsive than eating habits. So, um, yeah, I, I, I do think for our kids with obesity. I, I am much more likely to say you need to stay on it regularly, although in response to your question, she's, there are definitely some kids where you have to on balance, look at the side effects of the medication versus the, the benefits. Mhm. And I definitely, I definitely have a group of kids, I say, you're coming off because they, because they have, you know, they're, they're at 3rd percentile on weight and they're, you know, they're having blood pressure issues or they're having personality changes. I think another thing that um Shelly Kirk mentioned is sleep and sleep during the summer, which I think totally goes haywire all summer and we're really learning about the connection between obesity and sleep, you know, more and more, but um I think I'm usually surprised by the number of 9 and 10 year olds who will come in in the beginning and say, oh, we have to go back to school, so now we have to start going to bed and you ask what time they go to bed and they'll say 2 or 3 in the morning. Um, yeah, so I'm wondering what, what part sleep might play in some of this as well. They're staying up till 2 or 3 with their tablet too, which then just leads to other sleep issues. So. All right, I think that, I think that wraps up this section. Well, thank you, everybody. Uh, Jody, Kristen, Sheathel, fantastic job. We will be back at 2:40 Eastern time with adolescent bariatric surgery update and then rapid fire at 3:30. We'll see you shortly.