WHAT’S UP DOC? School Health and Wellness

A Pediatrician’sPerspective

WHAT’S UP DOC? School Health and Wellness

A Pediatrician’sPerspective

Claire LeBlancMD, FRCPC, Dip Sport Medicine

University of Alberta

Global Obesity Epidemic1

• More than 400 million adults were obese in 2005 worldwide

• Chronic diseases associated with obesity account for 60% of the 58 million deaths/year2 – Cardiovascular disease,

diabetes, some cancers, chronic respiratory diseases

1http://www.who.int/mediacentre/factsheets/fs311/en/index.html; 2 Preventing Chronic Diseases: a Vital Investment: Geneva, World Health Organization 2005

2003 Obesity Trends: Canadian Adults*

*P.T. Katzmarzyk, Unpublished Results. Data from: Statistics Canada. Health Indicators, June, 2004

No Data <10% 10%-14% 15-19% 20%

Children not Immune3

• In 2005 at least 20 million children under five years old were overweight globally1

• Up to 80% of obese youth continue this trend into adulthood Risk for chronic disease

and premature mortality

3 LeBlanc CMA, Gomez J et al. Pediatrics ,2006;117:1834-1842

Prevalence of Overweight & Obesity4

Canadian Children 2004 (2-17yrs)

0

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10

15

20

25

30

boys1978

boys2004

girls1978

girls2004

total1978

total2004

obese

overweight

4 Shields M. Statistics Canada 2005; 82-620-MWE;

Provincial Overweight & Obesity 20044

(children aged 2-17)

0

5

10

15

20

25

30

35

40

BC AB SK MN ON QC NB NS PEI NF

PR

EV

AL

EN

CE

50%

BC MN NB NS NFAL SK ON QU PEI

0%

4 Shields M. Statistics Canada 2005; 82-620-MWE

What are Some Co-morbidities of Obesity in

Youth?3

• Type 2 diabetes• Obstructive sleep apnea• Nonalcoholic Fatty liver (NAFLD)• Polycystic ovary syndrome• Hypertension• Hyperlipidemia• Focal segmental

glomerulosclerosis• Orthopedic complications• Depression/anxiety• Poor self-esteem, and lower

health-related quality of life

3 LeBlanc CMA, Gomez J et al. Pediatrics ,2006;117:1834-1842

Why are Kids Overweight?

• Excessive juice & pop• Low fruit/veggies• Low cereal fiber• Absence of family

meal• Fast-foods: fat and

energy • Mega-meals5

5 Newman C. National Geographic 2004;206(2): 46-60

Why are Kids Overweight?

• Too much TV watching– Strongly linked to obesity4

• Inadequate physical activity (PA) levels6

– Canadian 5-17 year olds average 11,356 steps/day by pedometer

• Need 12,000 -16,500 steps/day ~ 90 min mod-vigorous PA/day

6 CANPLAY: Physical Activity Monitor 2005. www.cflri.ca/eng/statistics/surveys/pam2005.php

Why Not Active Enough?

PA DAILY at home– TV, computer/video games– Unsafe environments Recreational facilities– Inactive parents

PA DAILY at school– 17% Canadian schools

(Elementary High) have daily PE by PE specialists7

7 Cameron C. Opportunities for PA in Canadian Schools: Trends from 2001-2006. www.cflri.ca

Benefits of Healthy Nutrition

• Malnourished children have8 – ↓ Physical activity & endurance– ↓ Cognitive function & school performance– Greater frequency of ADHD

• Omitting breakfast can interfere with learning even in well-nourished children

• School breakfast programs9

– ↑ School attendance– ↑ Math test scores

• Optimal growth & development• Obesity prevention

8Fanjiang G Curr Opin Clin Nutr Metab Care. 2007 May;10(3):342-7; 9Powell, CA. Am J Clin Nutr 1998;68:873–9.

Benefits of Physical Activity

• Aerobic PA ↓ Wt (obese kids)9

– Diet + exercise better than either alone10

– Lifestyle PA better than calisthenics or programmed aerobic exercise11

– Improved co-morbidities• Insulin resistance; fatty liver;

dyslipidemias

• ↑ Self esteem; ↓ anxiety & depression12

• May improve or not worsen academics13

9Owens S. Med Sci Sports Exerc. 1999;31(1):143-148; 10Epstein LH. J Consult Clin Psychol. 1984;52(3):429-43711Epstein LH. Behav Ther 1985;16:345-356; 12Kirkcaldy BD. Soc Psychiatry Psychiatr Epidemiol 2002;37:544-550;13Trudeau F, Shephard RJ. International J of Behavioral Nutrition & Physical Activity 2008;5:10:1-41

Behaviour Must Change…But

How?

• Historically strategies to ↓ obesity focus on individual behaviour change BUT…– Since 1950, US Federal agencies issued >

37 versions of guides encouraging Americans to ↓ energy intake & ↑ PA….YET…

– Obesity rates are still rising…

O

ITY

PREVALE

INDIVIDUAL

EnergyExpenditure

POPULATION

%

OBESE

OR

UNDERWTFood

intake :Nutrient density

FACTORSINTERNATIONAL

Development

Globalizationof

markets

SchoolFood &Activity

WORK/SCHOOL/

HOME

Infections

Labour

Worksite Food & Activity

LeisureActivity/Facilities

Agriculture/Gardens/Local markets

COMMUNITYLOCALITY

Health Care

System

PublicSafety

PublicTransport

Manufactured/Imported Food

Sanitation

NATIONAL/REGIONAL

Food & Nutrition

Urbanization

Education

Health

Social Security

Transport

Family &Home

NationalNationalperspectiveperspective

Media &CultureMedia

programs& advertising

Kumanyika Ann Rev Pub Health 2001;22:293-308

Comprehensive School Health Policy

• NEW FOCUS - DEVELOP PUBLIC POLICY – Create healthy behavioural norms– Shape environment where healthy

choices can reach entire populations• School environments reach large

populations of children who are– Vulnerable to marketing – Unable to make fully informed

decisions without guidance

• World Health Organization (Through Public Health Agency of Canada) is developing a School Policy Framework – Implement WHO Global Strategy on

Diet, PA & Health*– Promote healthy active living for

staff & students– Policies evidence based…

*http://www.who.int/dietphysicalactivity/en/index.html

Effective School Programs

• 13 Effective PA programs14 – 12 Randomized Control

Trials (RCT)– 11 school-based

• All increased PA• 6 ↑ fitness measures• 3 ↓ obesity measures• Most were late

elementary – high school

• 6 Effective programs to ↓ sedentary activity14

– 6 RCT; 4 School-based trials

– 5 ↓ Screen time– 2 Improved obesity

measures• Planet Health (2 yr) grade

6-7 students15

• Robinson’s grade 3–4 RCT16

14LeBlanc CMA. CMAJ 2007;176(8):chapter 22; 15Gortmaker SL. Planet Health. Arch Pediatr Adolesc Med 1999;153:409-18; 16Robinson TN. JAMA 1999;282:1561-7

Effective School Programs

• Wellness, Academics & You17 – 1013 4th & 5th graders ↑ PA &

veggies & fruit

– ↓ BMI; ↑PA; ↑ fruit & veggies

• Fitkids: 18 schools RCT after school program18 – Grades 3,4,5– Healthy snacks, 80 min/day PA– Improved % body fat & fitness– Summers off returned to

baseline

• 16 Effective multifaceted programs9

– All RCT– 7 trials > 1 year duration

• 3 increased PA• 5 increased fitness• 11 improved food

intake• 7 improved obesity

measures

17Spiegel SA. Obesity (Silver Spring). 2006 Jan;14(1):88-96; 18Gutin B. Int J Pediatr Obes. 2008;3 Suppl 1:3-9

Research Summary

• Schools are pivotal settings to promote healthy active living

• Multifaceted programs implemented in multiple settings targeting behaviour change rather than isolated knowledge acquisition appear to work best– Dedicated PE with a variety of aerobic activities– Active recreation before, after and during school– Healthy food and drinks in cafeteria, vending

machines– Parental and family involvement important

WHO Suggests

• Set up a School/District Wellness Committee

• Develop & implement policy – PA, food, curriculum, school health

services

• Monitor & evaluate – Process, output & outcome indicators

• Involve stakeholders EARLY

STAKEHOLDERS

Schools: Everyone Benefits from an Active Living

Workplace

• Trustees, Superintendents– Develop policy– Influential, secure resources, support

staff, bridge with external groups

• Principals– Leaders; promote & maintain

wellness programs for staff & students

• Teachers (Key implementers)– Require PE training, curriculum

aligned with academic mandates, support from principal, sufficient time & resources

• Students (Key recipients)– Should have a say in policy/programs

Parents & Extended Family

• School health program can influence family behaviour at home– Students change parent behaviour

• Parents can set a good example • Family can help with active living

homework assignments• Family can encourage & take part in

safe active transportation– Walking school bus

• Family can support school health policy and programs– PTA

• Family can lobby decision-makers to support health promotion in schools

Health Professionals: MDs

• Provide families with office-based healthy lifestyle counseling – Time? Sufficient?

• MD can set a good example• Support active school community

– Sit on school/district wellness committee

• Provide help with advocacy, research, monitoring, evaluation

• Physicians can provide knowledge translation – MDs, health organizations, general

public• Community wide education: Media• Letters to or meetings with key

decision makers

Dr. P. NiemanMarathon runner

Education & Health: United We Stand

• Canadian Council on Learning 2008*– 6/10 Canadian adults have insufficient

literacy skills to manage their health– Those with low health literacy 2.5 x

likely to have fair-poor health– MDs consulted most (74%) for health-

related information because of credibility

• Need more training in using simple language

– Media & family/friends consulted next (67%) but less credible – schools way down on list

• Opportunity for MDs to learn from schools on messaging & schools to learn from MDs on health-related matters

*http://www.ccl-cca.ca/CCL/Reports/LessonsInLearning/LinL20080306HowLowLiteracy…

Next Steps

• Alberta School districts & health regions showing– Best practice examples

• Workshops– Listen, learn, offer help– Create feasible action

plans for your region• Network of MD

champions– NEW MODEL– Local Region

Province

Alberta: Will be Canada’s BEST Province – When We Work

Together