Workshop with school nurses re: talking to parents about weight issues in children

1. TALKING TO PARENTS ABOUT WEIGHT:
INSIGHTS AND TOOLS TO ENHANCE METABOLIC HEALTH IN THE FAMILY

2. OBJECTIVES
▪ Review current methods to assess weight, body composition and metabolic health
▪ Learn how to reframe weight concerns in order to minimize resistance and
opposition
▪ Identify three key components to successfully address metabolic health with
families
▪ Disclosures
▪ Consultant for McDonald’s Owners of Southern California (MOASC)

3. ISSUES WITH OBESITY
▪ Is everyone getting fatter in the same
way?
35
30
25
▪ California adolescents
20
White
Latino
Afr. Am.
Asian
15
▪ At risk for overweight and
overweight statistics includes teens
with BMI> 85th percentile
10
5
0
At Risk
2000 CalTeens Survey, California Department of Health Services c 2004

4. TREATMENT OF PEDIATRIC OBESITY:
A SYSTEMATIC REVIEW
AND META-ANALYSIS OF RANDOMIZED TRIALS
Conclusions
▪ Limited evidence supports the short-term efficacy of medications and lifestyle
interventions
▪ The long-term efficacy and safety of pediatric obesity treatments remain unclear
McGovern, et al. J Clin Endocrinol Metab 93: 4600–4605, 2008

5. ASSUMPTIONS
ABOUT BODY
SIZE

6. WHAT ABOUT WEIGHT & RELATED
MEASURES?
PRO
CON
▪ “BMI provides a reliable
indicator of body fatness for
most people and is used to
screen for weight categories
that may lead to health
problems.”
▪ “Body mass index (BMI), based
on the weight and height, is not
an accurate measure of body
fat content and does not
account for critical factors that
contribute to health or
mortality”
http://www.cdc.gov/healthyweight/ass
essing/bmi/
http://www.sciencedaily.com/releases/
2013/08/130822141948.htm

7. THE DISTORTION OF BODY WEIGHT AND
BMI
THINLY MUSCLED
THICKLY MUSCLED

8. THE ISSUE WITH
WEIGHT
How weight is distributed
and how fat is stored are
more significant factors
impacting metabolic
health

9. NUTRITION EVIDENCE-BASED LIBRARY
(NEL) USED TO ESTABLISH 2010 DG
Methodological challenges
BMI is a poor surrogate measure of adiposity
▪ Using DEXA excessive body fat was found in
▪ 77% of children w/ BMI > 95th %
▪ 20% of children w/ BMI between 85-94th %
▪ 30% of children assessed as overweight had normal body fat stores
Arch Pediatr Adolesc Med. 2009;163(9):805-811.

10. ASSUMPTIONS
ABOUT FOOD
INTAKE

11. TREATING OBESITY
▪ Eat less
▪ Exercise more
Calories in < Calories out = Weight Loss
Q: IF OBESITY IS A MATH PROBLEM,
How many calories do you need to overeat each day to gain 10 pounds
extra fat weight over 5 years? _____

12. NUTRITION EVIDENCE-BASED LIBRARY
(NEL) USED TO ESTABLISH 2010 DG
Methodological challenges
Dietary assessment methods generally
lack the sensitivity to detect small
difference in energy intake
▪ Food Frequency
▪ 1-3 day food recalls

13. RELIABILITY OF DIETARY INTAKE AND BMI
▪ Overweight subjects reported to
underestimate calorie intake
McCrory, et al. The Degree of Misreporting of Dietary Intake. Public Health Nutrition: 5(6A), 873–882. 2002.

14. MEAN ANTHROPOMETRIC MEASURES IN CHILDREN 2-18
YEARS OF AGE (NHANES 1999-2004)
80
70
60
T. Candy -Cons
50
T. Candy- NC
40
Choc-Cons.
30
Choc-NC
20
Sugar-Cons
10
Sugar-NC
0
Weight (kg)
BMI
Waist Circ. (cm)
http://www.foodandnutritionresearch.net/index.php/fnr/article/view/5794/8675 c2011

15. CANDY CONSUMERS (N = 3,458) VS. NON-CONSUMERS
(N=7,724) (NHANES 1999-2004)
2400
2300
T. Candy -Cons
2200
T. Candy- NC
2100
Choc-Cons.
2000
Choc-NC
Sugar-Cons
1900
Sugar-NC
1800
Calories
http://www.foodandnutritionresearch.net/index.php/fnr/article/view/5794/8675. c 2011

16. TEN PUTATIVE CONTRIBUTORS
TO THE OBESITY EPIDEMIC
▪ Food supply & marketing practices
▪ Maternal age
▪
▪ Assortative mating
Physical activity
▪ Infections; gut microbes
▪ Sleep debt; stress; cortisol
▪ Perinatal epigenetic factors
▪ Endocrine disruptors
▪ maternal obesity
▪ over/undernutrition
▪ hyperinsulinemia
▪ Pharmaceutical iatrogenesis
▪ Ambient temperature
Critical Reviews in Food Science and Nutrition 49(10) 868-913 (2009)

17. WHERE CAN
WE START?

18. STOP FOCUSING ON WEIGHT
▪ Everything that we link
to weight can be
discussed in terms of
metabolic health
▪ Target true bio markers
of poor health
▪ Focus on
beliefs, attitude, emotion
s, behavior
▪ Avoid shame and blame

19. TRUE BIOMARKERS OF METABOLIC
HEALTH
▪ Biomarkers of poor
metabolic health
▪ Elevated blood pressure
▪ Elevated liver enzymes/Fatty liver
▪ Hyperinsulinemia/hyperglycemia/co
mpromised OGTT
▪ Elevated markers of inflammation (C
reactive protein)
▪ Dyslipidemia ( especially elevated
triglycerides/depressed HDL)
▪ Low hemoglobin, hematocrit
▪ Poor thyroid function

20. OTHER MEASURES OF METABOLIC
HEALTH
▪ How the body is using energy
▪ Hunger, satiety
▪ Fatigue, stamina
▪ Focus, concentration
▪ Temperament
▪ Body composition (higher ratio of fat to
muscle)
▪ Pattern of fat stores (central body fat)

21. NUTRITION FACTORS LINKED TO
METABOLIC HEALTH
▪ Function of food choices
▪ Poor food distribution
▪ Poor food composition at meals
▪ Excess/inadequate intake to meet
energy needs
▪ Nutrient density of food choices
▪ Excessive refined starches and/or
sugar
▪ Inadequate protein
▪ Inadequate fiber rich foods (fruits/
vegetables, beans & legumes, whole
grains)

22. EFFECTS OF MEAL HIGH IN CARBOHYDRATE
ON SATIETY IN PRE-PUBERTAL CHILDREN
NW
Obese
Lomenick J P et al. JCEM 2009;94:4463-4471
©2009 by Endocrine Society

23. EFFECTS OF MEAL HIGH IN PROTEIN
ON SATIETY IN PRE-PUBERTAL CHILDREN
NW
Obese
NW Pre-adol.
Obese Pre-adol.
Lomenick J P et al. JCEM 2009;94:4463-4471
©2009 by Endocrine Society

24. WHAT STARTS THE DAY?

25. WHAT’S FOR BREAKFAST AT LAUSD ?
Friday
Monday
No Milk
Wednesday
French
Toast
Thursday
Breakfast
Burrito
With Milk
Tuesday
LAUSD
Coffeecake
Pancakes
Fruit and
Oatmeal
Bar
58% CHO
22% PRO
61% CHO
21% PRO
57% CHO
14% PRO
71% CHO
18% PRO
61% CHO
14% PRO
63% CHO
22% PRO
68% CHO
13% PRO
60% CHO
5 % PRO
85% CHO
7 % PRO
66% CHO
6 % PRO
http://www.schoolmenu.com/menu/ca/lausd/los-angeles-elementary/ JAN 6-10, 2014

26. CORE MESSAGES
▪ 1. Move every day
▪ Not just about calories
burned
▪ Improved energy metabolism
▪ Greater glucose tolerance
▪ Improve insulin sensitivity
▪ Improved capacity to burn fat for fuel
▪ Increased focus, well being and
satiety
▪ Lower inflammation

27. CORE MESSAGES
▪ 1. Eat through the day
▪ Consider actual waking hours of day
▪ Avoid getting over-hungry
▪ Eating too little through the day
often triggers over eating
/excessive snacking later on
▪ Reasonable meals usually last 3-5
hours
▪ Ideally meals meet needs as
opposed to needs fitting into a rigid
meal structure

28. CORE MESSAGES
▪ 2. Adequate balance of
protein, carbohydrate and fat
to meet needs
▪ Different for different people
▪ Variable depending on
activity, stress, and other factors

29. CORE MESSAGES
▪ 3. Determine how much is enough
▪ Avoid getting over hungry
▪ Discern the difference between feeling
satisfied versus feeling full or overfull
▪ Portions count
▪ Check distorted assumptions
▪ More is better
▪ I already paid for it
▪ It’s free!
▪ Getting your money’s worth
▪ I don’t like to waste food

30. CORE MESSAGES
▪ 4. Allow food it’s rightful place
▪ Adequately address other needs
▪ Suggest , provide adequate language to
express feeling
▪ Build emotional intelligence
▪ Acknowledge without having to fix
▪ Build tool box to build resilience
▪ Effectively self regulate
▪ What works at 6 y/o ? 10 ? 14? 18?
▪ What works at 30, 50, 70 yrs of age?
▪ Effectively self soothe
▪ Cultivate wide enough range of options

31. CORE FUNCTIONAL CAPACITY
RESILIENCE:
SELF REGULATION:
THE ABILITY TO ACT IN YOUR LONGTERM BEST INTEREST, CONSISTENT
WITH YOUR DEEPEST VALUES.
BUILDING SKILLS TO ENDURE
HARDSHIP

32. Willingness
Readiness
Ability
Knowledge
Access
Resources
Self regulation
Resilience
BASIC
REQUIREMENT
S FOR CHANGE

33. TALKING TO PARENTS ABOUT
WEIGHT:
Thank you
Q&A
Bonnie Y. Modugno, MS, RD
www.muchmorethanfood.com