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*P.T. Katzmarzyk, Unpublished Results.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
5
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