Are Current Health Care Practices Propagating Obesity in our Youth? The Role of the Physician to Prescribe Solutions Thomas M. Best, MD, PhD, FACSM The Ohio State University Improving People’s Lives through innovations in personalized health care Sports Medicine What Motivates Change? • • • • • There is a crisis A critical mass of scientific evidence exists Shift in social attitude occurs Public cynicism grows Political pressures begin to build What Motivates Change? • There are 2 kinds of disease; one is pathological, the other is political Physical Exercise offers protection against a cluster of diseases Type 2 diabetes Cardiovascular Diseases Breast cancer Depression Colon cancer Pedersen BK. J.Physiology 2009 Dementia Exercise Deficit Disorder (EDD) in Youth • Walker GA, Edwards NM, Stracciolini A, Best TM, Faigenbaum AD, Myer GD. The Use of Exercisespecific V Codes and Reimbursement at a Large Pediatric Medical Center. AMSSM 2013. Youth Fitness and Sports Paradox • Survey of HS seniors: – Less than 25% of boys and 15% of girls exercise vigorously . – Childhood obesity is an emerging epidemic. • However; – Half the exercising group is actively involved on an athletic team, many participating all year. – Increased risk for orthopedic injury, especially related to overuse. Youth Fitness and Sports Paradox • The Changing Landscape of Playgrounds! – Most exercise obtained by children in America is no longer obtained in physical education class or free play; it comes through organized youth sports. – Children are less fit and obesity is growing, yet so is athletic injury! Physically Inactive kids at greater risk for injury! • Study of 995 children aged 9-12 years. – Low levels of habitual PA have significantly increased injury risk. • The children at highest injury risk are the target audience of the contemporary PA promotion efforts. • Therefore, PA promotion should focus on injury prevention as well. Bloemers BJSM 2011 Comprehensive Management Strategies for Management of EDD in Youth Myer, GD, Faigenbaum, AD, Stracciolini, A, Hewett, TE, Micheli, LJ and Best, TM (2013). "Comprehensive Management Strategies for Physical Inactivity in Youth." Current Sports Medicine Reports July/August. Why Kids Should Exercise • Compared to kids who don’t exercise, kids who do: – Can run longer and faster – Have stronger bones – Have stronger muscles – Are less likely to be fat – Have less stress and depression – Are less likely to develop chronic diseases – Are more likely to be healthy adults Exercise Helps Prevent: • • • • • • • • Diabetes Cancer (breast and colon) High blood pressure Depression Osteoporosis Alzheimer’s disease Heart attacks Dying early Physical Activity Improves Mental Health • Regular PA may increase self esteem • Regular PA may decrease anxiety/depression* • Some evidence shows teen girls have lower rates of sexual activity and pregnancy when PA increased • Some evidence regular PA associated with decreased smoking, alcohol and drug abuse K.J. Calfas, W.C. Taylor. Ped Exerc Sci 1994. 6:406-423 Sabo et al. J Adolesc Health 1999;25:207-16 Fitness And Stanford Achievement Test 9th Ed SAT-9 and Fitnessgram Results • Fitnessgram test: – 1. – 2. – 3. – 4. – 5. – 6. Aerobic Capacity Body Composition (% of body fat) Abdominal Strength and Endurance Trunk Strength and Flexibility Upper Body Strength and Endurance Overall Flexibility Grade 5 SAT 9 and Physical Fitness 353,000 Students 80 70 Reading Mathematics 71 SAT 9 Percentile 60 58 50 50 45 40 30 36 29 40 32 36 55 46 40 20 10 0 1 2 3 4 5 Number of Fitness Standards Achieved Source: California Dept. of Education Study, December 10, 2002 6 Grade 9 SAT 9 and Physical Fitness 279,000 Students 70 SAT 9 Percentile 60 Reading 67 Mathematics 58 50 51 40 38 35 30 20 45 43 28 24 21 37 31 10 0 1 2 3 4 5 Number of Fitness Standards Achieved Source: California Dept. of Education Study, December 10, 2002 6 Improvements in Fitnessgram Results PE 4 Life Program at 6 months Woodland Elementary School, Kansas City PSD Fall 2005 – Spring 2006, Grades 4 and 5 13.5 % Modified Sit & Reach Fall 2005 21.6 % Spring 2006  60% 16.5 % Push-Up  88% 31.1 % 12.4 % Paced Curl-Up  127% 28.1 % 19.4 % Pacer Test (Cardiovascular Fitness) Flexibility Test  207% 59.6 % 4.5 %  182% 12.7 % 3% Strength Test  433% 16 % 0% 10% 20% 30% 40% 50% 60% 70% Percent Reduction in Disciplinary Issues PE 4 Life Program at 6 months Woodland Elementary School, Kansas City PSD #33 Fall 2005 – Spring 2006, Grades 4 and 5 Discipline Incidents Involving Violence 2004 - 2005 2005 - 2006 228  59% 94 Resulting Out-of-School Suspension Days 1177  67% 392 0 200 400 600 800 1000 1200 1400 Fitness and Neurocognitive Function in Preadolescent Children • 24 children, mean age, 9.6 years • Fitness assessed by FITNESSGRAM • Neurocognitive function assessed by responses to a stimulus discrimination task • Fitness was positively associated with attention, working memory, response speed, and cognitive processing speed Hillman CH et al. Med Sci Sports Exerc 2005; 37:1967 How Much Physical Activity Do Kids Need? • Children and adolescents should do 60 minutes (1 hour) or more of physical activity daily. – Aerobic Activities: most should be either moderate or vigorous intensity PA. Include vigorous-intensity PA at least 3 days per week. – Muscle-strengthening Activities: at least 3 days of the week, as part of the 60 or more minutes. – Bone-strengthening Activities: on at least 3 days of the week, as part of the 60 or more minutes. • Activities should be age-appropriate, enjoyable, and offer variety. Kids exercise less as they get older Boys weekday 14.7 yrs Girls weekend 12.6 yrs JAMA. 2008;300(3):295-305. doi:10.1001/jama.300.3.295 % of High School Students Meeting Guidelines 100 Percent 80 60 40 20 23.7 17.1 18.5 15.5 14.9 Black Hispanic 10.5 0 Total Female Male White * Were physically active doing any kind of physical activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day during the 7 days before the survey. Source: National Youth Risk Behavior Survey, 2007. When are elementary school students active? 8000 7000 Steps per day 6000 5000 4000 Boys Girls 3000 2000 1000 0 P.E. School Day Outside School Morgan CF, et al (2003) Journal of Physical Education Recreation and Dance, 74(7), 33-38. Chronic Disease in Children • Pediatrics; Nov 08’ Number of children taking meds for chronic diseases jumped dramatically in past 3 years. – Diabetes 103% increase (kids as young as 5) – Asthma 47% increase – ADHD 41% increase – Cholesterol 15% increase “The Freshman 15?” • Studies suggest actual weight gain during 1st year of college is: – ~6 lbs in men – ~4.5 lbs in women • What are the causes? – Not enough exercise – Poor diet – fast food, dormitory food, skipped meals – Poor sleep habits – Stress Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2000 1990 2010 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Are patients and their physicians giving up? • Data from National Ambulatory Medical Care Survey for 1995-96’ and 2007-08’ showed: – During this period, adults who were overweight or obese increased from 52.1% in 95’ to 63.3% in 08”. – Patients seen in 2007-08; had 46% lower odds of receiving weight counseling than 95-96’. – Patients with hypertension 46% less likely and diabetics 59% less likely to receive counseling. • The campaign on obesity is not working! • What’s the definition of insanity? Kraschnewski, et al, Medical Care, 2013 We need a new (and fresh) approach! • We need to give patients permission to be fat, and still be healthy! • Shift focus off of BMI and onto physical activity. • Health At Every Size (HAES) – Focus on broader health – 95% regain lost wt. in 3-5 yrs – Change in BMI is not a success measure for an exercise program What can we do? • Large scale exercise prescription initiative in adults and kids: – Every patient; Every visit; Every treatment plan. • Physical activity should be recorded as a vital sign and kids encouraged to do 60 min of exercise per day. • Message should be the same from every medical provider. • We must begin to merge fitness with healthcare. What Can Busy Physicians Do to Encourage Physical Activity?  0 Minutes: Running late? Too many other concerns on the patient’s list? Relax. Perhaps you can discuss physical activity at next visit. Hopefully office staff will have assessed exercise and provided resources. 1 Minute for Advice: Quickly congratulate kids (and their parents) who are getting 420 minutes or more per week of moderatevigorous physical activity. Advise patients who are getting fewer than 420 minutes of the importance of physical activity, especially linking benefits to the child’s complaints, problems and health risks. What Can Busy Physicians Do to Encourage Physical Activity? 2 Minutes for a Prescription:  Review key messages about the importance of physical activity.  Offer a generic Exercise Prescription.  Suggest useful ideas (e.g. walk to school, bike transportation, active games, after-school activity, family fitness activities). 5 Minutes for Brief Counseling:  Assess readiness for change regarding exercise habits.  Ask what the child might want to do to be more active and barriers to prevent this from happening -- brainstorm on how to get around them.  Explain to parents in detail how exercise affects health and development and their child can go about incorporating it into their life. Summary • Youth sports/activity paradox – kids are doing too much or too little • The wide ranging benefits of PA in kids and adults are well established • We need to encourage kids to be Healthy at Every Size by engaging in regular PA • Physician have an important role to play in promoting PA for health – An Exercise Vital Sign is an easy way to bring a discussion on PA into the exam room – Even brief advice can have a significant affect