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Roots of Health and Wings of Wellness: Engaging Youth in Healthy Lifestyle Management to Counter Pediatric Overweight and Obesity Wasim Saadeh, M.D., Susan Akers, RDN, and Janeen Leรณn MS RDN

Latino Childhood Obesity - Objectives ď‚´ 1. Understand the trends in pediatric obesity and how this will impact the health outlook for the next generation of adults. ď‚´ 2. Identify key behaviors and traits that contribute to the increased risk of overweight and obesity in the pediatric Latino population. ď‚´ 3. Learn how the Pediatric Weight Management and Wellness Program at MetroHealth is addressing these risk factors and educating families on healthier living.

Childhood Obesity – How BIG is this problem?

• In 2012, 1/3 of U.S. children were overweight or obese • Rates have more than doubled in children and quadrupled in adolescents in the past 30 years

Childhood Obesity by Age Groups Infants – 2yrs old 6-11 yr olds

12-19 yr olds

 8.1% have high wt:length  18% obese up from 7% in 1980

 21% obese from 5% in 1980 (12.3% of these met severe obese)

>20 yr olds

CDC 2014

 34.9% obese

High BMI can have negative effects on a child’s whole body and mind!

Childhood Obesity can lead to….  High blood pressure and high cholesterol, which are risk factors for cardiovascular disease (CVD).  Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes.  Breathing problems, such as sleep apnea, and asthma.

 Joint problems and musculoskeletal discomfort.  Fatty liver disease, gallstones, and gastro-esophageal reflux (i.e., heartburn).  A greater risk of social and psychological problems, such as discrimination and poor self-esteem, which can continue into adulthood.

Rates of Childhood Obesity by Ethnicity National Rates of Childhood Obesity(2-19yrs)  22.5% of Latino Children

 20% of Black Children  14.1% of White Children

Cuyahoga County Board of Health Cle Dept. of Public Health, Oh Dept. of Health, Gallup, Health Improvement, 2015

Severe Childhood Obesity Fastest-growing subcategory of obesity in children and adolescents (2-19y) Define: BMI >120% of the 95th% or >35 kg/m2  Non-Hispanic whites = 4% boys, 3.5% girls  Non-Hispanic blacks = 7.1% boys, 9.1% girls  Hispanic = 6.9% boys, 5.1% girls

Data consistently have shown higher prevalence for severe obesity among Hispanic or Mexican American children and non-Hispanic black or African American youth

Kelly AS, S Barlow et al. Severe Obesity in Children and Adolescents; Identification, Associated Health Risks, and Treatment Approaches. Circulation. 2013;128:1689-1712

Rates of Childhood Obesity in Cleveland Cleveland ď‚´2013 Youth Survey found 29% of children met criteria for overweight and obesity

Cuyahoga County Board of Health Cle Dept. of Public Health, Oh Dept. of Health, Gallup, Health Improvement

MetroHealth 1999-2007 Ages 2-18 years Weight Distribution=60,711 41.8% overwt or obese = 25,377 7.7% severely obese 4,662 15.5% obese 9,423


overweight 11,292

58.2% normal or underweight

35,334 Benson L, Baer H, and Kaelber D. Pediatrics 2009;123(1):e153-e158

Inequities in Chronic Illness Latinos are disproportionately affected  Diabetes - 16.9% of Latino adults have compared with 10.2% of Whites Estimated that 52% of Latino girls today will develop diabetes in lifetime  Metabolic syndrome significantly higher, 50% among Puerto Rican women  Stroke - 43% of Latinos - leading cause of disability and 3rd leading cause of death Narayan K. Diabetes Care 2006; 29(9):2114-2116.

Rodriguez CY. "Beautiful but deadly: Latinos' curves put them at risk." October 17, 2013 (accessed May 2014)

Weight problems NOT “out-grown”

 Children who are overweight or obese as preschoolers are 5 times more likely than normal weight children to be overweight or obese as adults

CDC 2013

“Roots of Health and Wings of Wellness”

Susie Akers RDN, LD, HC, BCS Manager of the Pediatric Weight Management and Wellness Program

Childhood Overweight and Obesity Risk for the Latino Community

Latino children are at greater risk Higher rates of hunger or food insecurity

Higher rates of exposure to unhealthy foods Limited access to safe places to play

The State of Obesity and Health Disparities; A conversation on the latest research and recent policy efforts. Oct 2014

Early excessive weight gain  Latino children have the highest rates of early childhood overweight and obesity of any racial or ethnic group.  Risk for excessive weight gain and later obesity starts as early as infancy.  Contributing factors include;  Nonexclusive breast feeding, sugar sweetened beverage consumption, excessive screen time and decreased activity.

Ogden, CL Carroll MD et al (2012) Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA 307, 483-490. Plok S, et all Rapid infant weight gain and early childhood obesity in low-income Latinos and non-Latinos. Public Health Nutrition; 19 (10), 1777-1784, Nov 2015

Lack of food access and impact on food choices Low-income Latino families;  Buy higher amounts of sugar-sweetened beverages, pizza, chips, desserts, burgers and soda/juice  Spend about 1/3 of income on food  Food purchased is calorie-dense, low in fiber and high in fat, sodium and carbohydrates  Have 1/3 the number of supermarkets as non-Latino neighborhoods

Wilson TA, Adolph AL, Butte NF. Nutrient adequacy and diet quality in non-overweight and overweight Hispanic children of low socioeconomic status: the Viva la Familia Study. J Am Diet Assoc., 109(6): 1012-1021, 2009. U.S. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance — United States, 2013. Morbidity and Mortality Weekly Report, 63(SS04): 1-168, 2014

Food choices Vegetables - 2013 Youth Risk Behavior Survey  9.3 % of Latino youths did not eat vegetables during the prior week, compared to 4.5 % of White youths.

Advertising  84% of youth-targeted food advertising on Spanish-language TV promotes food of low nutritional value Lack of participation in Government support programs  In 2011, 34.9 percent of all Latinos were eligible for SNAP but only 21.4 percent received benefits. Bridging the Gap and Salud America!, Healthier Marketing and Latino Kids, Issue Brief, August 2013 Fact Sheet: Hunger and Poverty in the Hispanic Community. In Bread for the World (accessed May 2014).

U.S. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance — United States, 2013. Morbidity and Mortality Weekly Report, 63(SS04): 1-168, 2014

Income Matters  Highest rates of childhood obesity with income-to-poverty ratio of 100% or less (household income that is at or below the poverty threshold)  Nearly 25% of Hispanic households are food insecure  23% of children in poverty are Latino

 If current trends continue, by 2030 44% of children in poverty will be Latino  23% of Latinos are living below the poverty line with White families earning $2 for every $1 Latino families earn

Macartney S, Bishaw A, Fontenot K. Poverty Rates for Selected Detailed Race and Hispanic Groups by State and Place: 2007-2011. Washington, D.C.: U.S. Census Bureau, 2013 (accessed May 2014). McKernan S, Ratcliffe C, Steuerle E, Zhang S. Less Than Equal: Racial Disparities in Wealth Accumulation. Washington, D.C.: Urban Institute, 2013 (accessed May 2014).

Underutilization of Food Resources in Cuyahoga County Race/ ethnicity

Cuyahoga Co. Population %

% Poverty

Food Bank Use %

WIC Use %



18-64 yrs 25% <18 yrs 39%



Non-Hispanic Black


18-64 yrs 31% <18 yrs 52%



Non-Hispanic White


18-64 yrs 13% <18 yrs 18%



Parents as Role Models – Physical Activity  In 2014, Hispanic adults were 30% less likely to engage in active physical activity as Non-Hispanic Whites. 22.5 % of Latino youth did not participate in at least one hour of daily physical activity during the prior week 23% of Hispanic parents report neighborhoods were unsafe Latino children are less likely to be in after-school activities where they are physically active, due to factors including cost of participation, transportation and language barriers

 Latino children spend 13 hours each day engaged in various forms of media—nearly 4.5 hours more than white children who spend about 8.5 hours per day using media.

Acculturation and Dietary Behavior  Acculturation among Latinos  Negative influence on breast feeding, infant feeding, and quality of the diet consumed by children, adolescents, and adults.  Hispanic youth  Diets higher in energy, sugar and sodium, and more calories coming from fat and saturated fat compared to all racial/ethnic youth groups in US  The VIVA La Familia Study  68% of dietary energy included soda, desserts, pizza, snack chips, fruit drinks, fruit juice, processed meats and burgers which are high in fat, sugar, and/or sodium  Parents level of acculturation predictive of elevation in BMI z-score over time. Pérez-Escamilla R, J Nutr. 2007;137:860–70. Ayala GX, J Am Diet Assoc. 2008;108:1330–44. Dixon LB, Third National Health and Nutrition Examination Survey, 1988-1994. Am J Epidemiol 2000;152:548–557. Wilson TA, J Am Diet Assoc. 2009 June; 109 (6): 1012-1021. Hughes S, Journal of Obesity; vol 2016

Indulgent Feeding Styles and Parenting  Letting the child eat what and as much as they want - associated with higher child weight status.

 Indulgent parenting style, common in Hispanic families, uses food to show love and affection.  Interferes with self regulation and usually decreased intake of fruits, vegetables, dairy  Division of Responsibility – Parents roles vs children roles (where, when, what)

J Dev Behav Pediatr. Author manuscript; available in PMC 2009 October 28. Hughes S, et al. Maternal Feeding Styles and Food Parenting Practices as Predictors of Longitudinal changes in weight status in Hispanic Preschoolers from low income families. Journal of Obesity; vol 2016

Proposed Solutions  Ensure community-based obesity prevention and control strategies are culturally and linguistically appropriate  Provide education to Latino parents about childhood obesity improved nutrition – SNAP, WIC  Partnerships between government, businesses, faith-based groups, community organizations, schools and others  Increase access to and utilization of promotores (community health workers, peer leaders and health advocates)

Racial and Ethnic Disparities in Obesity, Latino Communities Special Report htttp://

Center for Disease Control & Association for Supervision and Curriculum Development’s “Whole Child”

MetroHealth Programs to Address Childhood Overweight and Obesity Strategies must be sustainable and comprehensive — targeting the challenges that stem from neighborhoods, schools, workplaces and marketing environments that make it difficult to access healthy affordable foods and be physically active.  Nutrition Exercise and Wellness (NEW) Clinic  Pediatric Wellness Center (PWC)  Peer Breastfeeding and Breast feeding Clinic  School-based Health  City Fresh, Healthy Living Kitchen  Mi MetroHealth, Mi Communidad, now La Placita  Community outreach – VIDA!

“Roots of Health and Wings of Wellness” Janeen León MS, RDN, LD Outcomes from the Pediatric Weight Management and Wellness Program

MetroHealth Pediatric Weight Management and Wellness Program Aamoth Wellness Center

Pediatric Specialists

The Family

School Based Health

N.E.W. (Nutrition, Exercise and Wellness)

MetroHealth Pediatric Weight Management and Wellness Program Nutrition Exercise and Wellness Clinic (N.E.W) Multidisciplinary clinic for children and their families to receive medical, psychological and nutritional screening and counseling related to individualized risk factors for co-morbid diseases related to overweight and obesity Comprised of:

 Physicians - Identify/screen for co-morbidities  Psychological - Behavioral assessment and counseling  Dietitian –nutrition monitoring and weight checks  Care Coordination – assist with specialty medical screening and visits

 Data Collection – biometrics

MetroHealth Pediatric Weight Management and Wellness Program  Aamoth Family Wellness Center Est. 2011  Free fitness and nutrition classes for patients/families  Children participate after medical appointments or any day after school &/or summer camp - over 8000 visits  Group classes or select 1:1 visits  Nutrition topics on cooking, portion control, snacking, gardening, shopping tips, etc.

 Fitness for cardio, strength training, team building  Behavioral health topics; sneaking foods, whole family support, limiting video or screen time and healthy body image

Healthy Plate Approach

NYC Health

5-2-1-0….Let’s go!

MetroHealth – CareSource Pediatric Weight Management and Wellness Program March 2014- February 2016 Participants: 1007 total CareSource participants since program inception Gender: 43% Male and 57% Female  Age: Mean 11.2 years (5-18 years)  5-10.9 yrs = 49%, 11-13.9 yrs = 27%, 14-18.9 yrs = 24% Race/Ethnicity: African American = 42%, Hispanic = 34%, White = 17%, Other/na = 7% Locations: NEW Clinic, PWC, 7 schools, 4 day/extended cares

MetroHealth Pediatric Weight Management and Wellness Program Baseline BMI%ile Categories, % N=841


Morbidly Obese (99.0%ile+)

81% Intervention


Obese (95-98.9%ile)


Overweight (85-94.9%ile)





Baseline Weight Status of CareSource Participants All (n=998)*

With 2+ data points (n=771)

Typical 11.2 yr boy

146.9 (65.5) 44-459

145.3 (65.4) 44-406


BMI (kg/m2), mean (SD) % > 30 (adult cutoff)

28.9 (7.7) 37% 0

28.9 (7.8) 37%


BMI %ile for age/sex %Overwt (85-94.9) %Obese (95.0-98.9) %Morbidly obese (99.0+)

97.0% (3.4) 20 44 36

97.1% (3.2) 19 45 36


2.1 (0.5)

2.1 (0.5)


Weight lbs, mean (SD) range

BMI z-score for age/sex

Enrollees March 2014 – February 3, 2016 – *Baseline data n/a for 9 of 1007 enrollees

A High Risk Population: Associated Comorbidities Comorbidities

MH Cases Diagnosed

Literature Review Prevalence in Children

Prevalence in Obesity

Cardiovascular (Dyslipidemia, HTN)

198 (41%)

HTN 4%


Respiratory (OSA, Asthma)

128 (26%)

OSA 1-3%


GI (NAFL, GERD, Constipation)

193 (40%)

NAFLD 3-10%


4 (1%)

T2DM 0.25-0.5%

5000+ new cases/yr

Derm (Acne, Acanthosis)

334 (68%)



Behavioral Health (Depression, Bipolar, Schizophrenia, Conduct)

70 (14%)

Depression 2-8%


Endocrine (DM, PCOS)

Total Visits by CareSource Participants March 1, 2014 â&#x20AC;&#x201C; February 3, 2016 Total Number of Visits by Visit Type

Number of Visits/ Participant Mean (range) N=1007

Total CareSource Participants


Multidisciplinary NEW Clinic w/MD Registered Dietitian Nutritionist


0.5 (0-6)


1.2 (0-19)

PWC (Trainer/Diet Tech)


4.0 (0-216)

Total Visits


5.7 (0-225)

Care Coordination Contacts


2.2 (0-18)

Weight Change Parameters n=771 Parameter

Number of enrollees (%) with Improvement

Weight Total pounds lost Total height gained

141 (18%) 790 pounds 1167 inches


259 (34%) 0

BMI% for age/gender

417 (54%)

BMI z-score for age/gender

428 (55%)

0.15 reduction* 0.25 0.50 Enrollees March 2014 â&#x20AC;&#x201C; February 3, 2016

133 (21%) 76 (13%) 20 (4%)

Behavioral Results Manually abstracted for year 1 from Epic clinical notes For subset of 108 CareSource patients with 2 or more surveys Baseline N=108

2nd Survey F/u N=108

Intraindividual Change 2nd; median 50 days

3rd Survey f/u N=70

Intraindividual change 3rd; median 107 days

5 Fruits and Vegetables Typical servings/day, mean % reaching goal % reporting increased intake

2.0 2%

2.4 5%


2.4 7%


2 Hours Screen Time Hours, mean % reaching goal % reporting decreased time

4.1 27%

3.4 44%

- 0.7

3.5 51%


1 Hour Physical Activity Hours, mean % reaching goal % reporting increased time

0.7 46%

0.7 52%


0 Sweet Drinks Servings, day % reaching goal % reporting decreased intake

2.5 20%

1.5 37%





-1.3 77%



1.0 57%


1.0 44%




Behavioral Results Baseline N=108

Fast Food Meals/Week Typical servings/week, mean


Manually abstracted for year 1 from Epic clinical notes for subset of 108 CareSource patients with 2 or more surveys completed.

2nd Survey Intraindividual F/u Change N=108 Median time 50 days 1.0






% reporting decreased intake Junk Food Servings/Day Servings/day

% reporting decreased intake



3rd survey f/u n=70

Intraindividual change Median time 107 days







Family Surveys  “My

kids get to participate in different activities and they learn a lot”

 “Motivated to eat healthier and exercise at home”  “Stopped drinking juice and pop and eat more fruits and vegetables instead of fast foods.”  “Mom has started baking now instead of frying, and her daughter is trying vegetables more”

 “Joined a soccer team at school now and eating healthier”

PWMWP phone survey Sept 2015

Questions? Wasim Saadeh, M.D. Susan Akers, RDN, LD, HC, BCS Janeen Leรณn MS RDN

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Roots of Health and Wings of Wellness  

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