Pediatric Obesity: Diabetes Prevention in the Latino Population

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good morning everyone welcome welcome get yourself a cup of tea or a cup of coffee and settle in on this dreary februari morning for those of you who are regular attendees you know the drill could you everyone please as you leave fill out an evaluation form it's very important for us as we plan this series and the end the months and years ahead if you'd like to sign up for continuing education credits APA credits CMEs you also need to fill out an additional evaluation form that is in the back of the room and also sign in and out so it is my absolute pleasure to introduce to you this morning someone that you probably already know dr. sherry Barkin and sherry has a very interesting history she's been kind of all over the place she got her bachelor's in zoology and education I didn't know that about you alright at Duke University and then she went on to get her MD at the University of Cincinnati and did her pediatric fellowship at Children's Hospital of Los Angeles and then earned her degree in health services research at a place that's near and dear to me UCLA and we were fortunate enough to recruit her here to Vanderbilt where sherry has just in my mind not only assumed a leadership position as the division chief of general Pediatrics which is a daunting task but she has also really pioneered and launched a line of research that will hear about this morning that in my mind is some of the most important work that pediatricians could ever do I sherry is the marian wright edelman professor of pediatrics and as I thought about this morning I thought you know what a perfect chair for you because I think just like Marie right our marian wright edelman didn't shy away from hard things Sherry's research doesn't shy away from hard things you tackle some of the hardest questions about children violence and kids obesity notnot little minor things huge problems and I you're doing a fantastic job so with a warm welcome on this dreary day please join me in welcoming sherry Barkin good morning everybody well that's certainly brightened my dreary februari day thank you for such a lovely introduction and it really is an honor to be here today to talk with you about a topic I see many colleagues in the audience several experts in the area of obesity so the first part might be review for some of you I just want to make sure we all start from the same place so that we can dive deep into the questions look at some potential solutions and then hopefully engage in an interesting discussion I'm going to be talking today about pediatric obesity prevention and control in the Latino population and our objectives this morning are to understand the scope of the problem of pediatric obesity identify contributing factors to the epidemic understand pediatric obesity linked to diabetes in Latino populations and then learn about some promising strategies to address pediatric obesity for Latinos and i'll be presenting some of our research so raise your hand if you've seen this this is from the cdc website right now while i notice that only about ten percent of you raised your hands which is why I still put it in and why why if you have seen this before i'm going to ask you to focus your eyes a little bit differently so the cdc started in the mid 80s looking epidemiologically to see what's going on with obesity for adults not for children this is just adults and they looked over this span of time so we're going to take you through the 1990s which feels like a long time ago 1985 when we really weren't doing much surveillance and we're going to go very quickly I want it to be like a movie for you so let me just orient you to color so if it's if it's blank it's because we had no data we weren't doing surveillance yet if fewer than ten percent of the adults in this eight are morbidly obese BMI greater than 30 that's going to be a lighter blue color as it becomes darker blue we're up to fifteen percent the colors will change and you'll start to see yellow and then orange as we move to greater than twenty percent and greater than twenty-five percent of adult populations who are morbidly obese now for those of you have seen this I want you to focus your eyes find our state so fine Tennessee don't worry it's not a geographic lesson although I'm learning a lot of that from my children relearning it so I want you to focus on Tennessee and specifically the surrounding southeast area so are you ready we're just going to go quickly through this and I'm going to I'm going to stop at points that I think were nidus points that really change the slope of the curve for obesity accelerating in America so everyone see Tennessee southeast focus there and we're going to move tonight to see where in 1996 now did you see how quickly that went from blue to yellow so 1997 299 k yellow greater than or equal to twenty percent of the adult population so once you to think 1999 what happened what happened that that made this epidemic look like it tips so keep watching southeast region do you see we get orange where does it happen first southeast region and then what happens it's like a contagion it spreads so we seem to be the hotbed of where the epidemic seems to increased first and how it then spreads across the country this dark orange color greater than or equal to thirty percent of the adult population not as overweight but as morbidly obese and that was the last slide so I want you to see and understand the questions that we started to ask and I actually most my research when I was in California my research was all about violence prevention I'm a public health scientist I'm a health services researcher and all of my questions come from what i see in clinic and i was inspired to really investigate violence prevention because it seemed like I was seeing absolutely preventable things walking into the emergency room in the clinic and I switched to obesity about six years ago because in the clinic I noticeably could see that over a seven-year period of time of me being in clinic I could see in my Latino families with my own eyes no microscope needed that this had become an epidemic that had tipped in North Carolina so and i was there in 1999 and i was there in 2004 so what happened I want you to just think about that in your in your mind what would happen to make something tip like that so what about childhood obesity as I mentioned those slides have nothing to do with children or do they do adults have something to do with children does adult obesity have something to do with childhood obesity I would pause it absolutely multiple mechanisms for why we believe that that's true so in childhood obesity and sort of raise your hands if you know definitions of obesity in children okay so obesity is defined as an excessively high amount of body fat or adipose tissue in relation to lean body mass I saw an eight year old in clinic when I look at this chart before we went in it looked like he was going to be morbidly obese and I'm when I walked in for this eight-year-old he had muscles like he was a 16 year old and we actually diagnosed precocious puberty for him he didn't have an adipose tissue at all so just having a high BMI which we'll talk about in a minute doesn't make the diagnosis you have to look at the body habitus now because children grow at different ages and because the genders grow differently the CDC provides this guideline for how we say are you wait and are you obese it's beyond wait its body mass index and that looks at your weight in relationship to your height and when I talk to families in clinic I don't say the CDC guidelines indicate that you are morbidly obese and I'm with my Latino families I don't even say sobre pesos I don't say overweight I say your weight is growing much faster than your height that's not good for your health that's what body mass index is about so overweight and it's recently redefined in the past two and a half years from the CDC overweight is defined is greater than or equal to the 85th percentile of age gender specific I'm going to explain what that means in a minute and obese defined as greater than or equal to the 95th percentile for age and gender specific and studies suggest that cutoff points are not Universal for ethnicities so let me just briefly explain what is this percentile thing all about so raise your hand if you have children or grandchildren in your life so when you go to the doctor's office they might show you our curves we're looking to see if you're growing along your own curve and if it's somewhere in the normal range so we say greater than the fifth percentile less than the 90th percentile of growth along your curves usually is normal and healthy although we've been learning that rate of rise for how fast you grow for your weight more excessively than your height actually does appear to be a risk factor so we're looking at percentiles and I'm about to tell you that more people that one in four children walking into our clinic are overweight and you're going to say that doesn't make sense because that's greater than the 85th percentile shouldn't that be fifteen percent of people in not twenty-five percent and so what happened is we held these curves constant we noticed that the rate of rise for weight was excessive defies how genetics can change so quickly over a short period of time as we look at to be with and instead we held the curves constant to say this is still what we believe healthy growth patterns are and we now have an excess amount of children that are growing in ways that are not healthy that's why these percentiles might not fit together as you're listening to the next part of the story so what is the connection between childhood and adulthood obesity in two thousand fifteen percent of children and adolescents aged six to nineteen were overweight so that's that greater than or equal to the 85th percentile that still makes sense right up from the fifth percentile in 1970 overweight adolescents have a seventy percent risk of becoming overweight or obese adults and sixty percent of overweight children not obese yet overweight ages five to ten already have one or more risk factors for heart disease or diabetes now what that means is that what I believe this data tells us is that obesity starts early that means prevention is going to have to start early and it gets harder and harder to intervene upon one other point that isn't on this slide that I think is important is that we know that if you are a preschooler so you're 325 and you're overweight you are two to five times as likely to be overweight in elementary school it's almost like a chronic disease it gets worse over time there's a disproportionate effect with minority populations now these data come from the CDC and they're updated regularly these data do not match what I see in clinic and we see 35,000 patient visits on the eighth floor dr.

Desmond can attest to that who's in the audience as well we see a lot of kids enough as a population-based scientist that it makes me say that I think these statistics lag behind what reality is so a four to five year olds white children four to five percent are overweight for African American children the same age twelve to fifteen percent are overweight for 25 year olds and for Latino children 24 to 27 percent are overweight I'll be presenting data from our randomized control trial that show numbers that are much higher than this for preschoolers so what's going on it seems that there's a disproportionate impact and this as many answers will be a complicated answer there are multi multiple things that contribute to this one is culture so in studies of mexican-american mothers sixty percent of them misclassified their child they did not see their child as overweight and they didn't see them as unhealthy and the majority of mexican-american mothers did not see a connection between weight and health so if you have a contact with Latinos in your in your life personal or professional life we raise your hands so do you know the word gordito go to Victoria go to dethaw it means chubby it really means to rubik and in fact it's used as a term of endearment and in this is not new to Mexican American families this is very much of an immigrant phenomenon so I know that my grandparents when they looked at me at my parents and they looked like they had chubby cheeks they felt prosperous they knew that they were doing a good job as parents that's not the specific culture there is a sense an immigrant sense that when you come with nothing and you try to build something for your family you want to see overt signs of prosperity that might not be the change in your pockets that jingles when you walk it might be the way your child looks and how heartily they eat this goes across many cultures and is very very prominent in the Latino culture which really views love and food inextricably I can think of many other cultures that do that as well I love this picture after short stay in America Michelangelo's David statue has been brought back to Europe so what happens to our immigrant families after they arrived in America by their second generation their health declined and they become more obese they have more incidence of diabetes they have more incidents of heart disease so it appears that America might not be that good for your health now why would that be so this is a review I'm expecting many of you already know this but I want to make sure we're all moving forward together so we can ask questions together so you know many people have a bias when they see somebody that doesn't look right they cross the other side of the street I I believe that we are a society that really does not see obesity as beautiful we see people as gluttons we say can't they eat less why aren't they turning the TV off and being more active can't they just take some personal responsibility now you're going to see that that is those are some important questions this is a much more complicated problem and i would like to sort of lay out that evidence for you so that you can understand why is it more complicated than just turning the television off which i still advocate by the way so energy balance it's all about calories in and calories out right so i'm in the newborn nursery now attending on service we've got a premature baby losing loads of weight taking loads amount of calories in we've increased those calories we're making sure that this child is eating very efficiently because we don't want this child to burn any excess calories why is he still losing weight something else is revving up his motor is it infection is it that his temperatures dropping and he's working too hard to keep his temperature up there's a lot that goes into that energy balance equation some of it that is internal that you can't see and some of it that's external I draw the sea salt for our family when they come in to understand that so what's going on in both sides of our seesaw right now in America so we've got not such great dietary intake you know how many vegetables we're now supposed to eat a day how many servings nine Yvonne got that right most of us were thinking 5 i'm happy to get 59 what percent of people in America that are not vegetarians get nine servings any ideas three percent so this is not easy for any of us soft drink consumption has more than double this is data from a longitudinal study of child development in Quebec it suggests that children who regularly consume sugar sweetened beverages so that's our terminology for that includes Gatorade by the way sorry to report iced tea sweet iced tea sodas from ages two to four years were more than twice as likely to be overweight by the time they're preschoolers so when that that 12 month old rolls into our clinic and he's got coke in his bottle that doesn't that doesn't fare well for him right now only three percent of populations meet the requirements I'm afraid I'm even one of them and I'm really thinking hard about this it's hard to do now portion sizes so what we eat going in isn't so good and how much we eat is huge so we know that we like big gulps we know that everything comes in giant cups I remember when I was seven and we went out to hot chops for for dinner I got a six-ounce cup and I got one I didn't get they didn't keep refilling it mindlessly we know about the supersize meals being one day's worth of calories one super-sized meal and though we've seen some positive change in that direction we have change agents in this audience working on that problem right now so portion size so just a word about that we know that we are mindless eaters we eat whatever is in front of us there is fabulous and fascinating data about this data that shows you that if I give you stale popcorn that has been sitting out for two weeks and I say it's free and you come in and I give you a small container or I give you a big container people will eat to the bottom of the bucket but my favorite study that has been done and I think that this was done at Yale correct me if I'm wrong it's either Yale or Oregon where they had the the soup bowl that refills so now here's the idea they gave you soup they said you know stop on your phone basically so here's your bowl of soup but they rigged up a bowl of soup so that it can blithely kept refilling itself you couldn't see it you know you're not noticing how soup is being used up those people that had their bowl refilled over and over again ate three to five times as much we are constantly overriding our homeostatic mechanism for eating we are mindless eaters now that's important it's an important contributor to this problem when you think about our built environment and when you think about portions that are served in restaurants and package sizes you purchase in the grocery store now what's going on for the out part of this energy expenditure equation well for hours a day the average American four hours a day engaged in media use that's when we didn't have all of that fancy handheld device that allows me to actually watch soap operas on my cell phone I can do that I'm not doing that I could do that right so it doesn't include the instant messaging we don't know what to make of that what is that that's sedentary I'm pretty sure we don't burn a lot of calories when we do that so it really works to be and in fact we calculate this in our weight management clinic we have doubled the number of clinics that we have for weight management clinic and general Pediatrics to serve the demand and what we find on average is that these kids are watching more than 40 hours more than 40 hours of screen time a week and I say to them that's a full-time job that is a fault without benefits so new physical demands are built into daily life we were meant to be in agrarian society so we were meant to actually expand a whole lot of calories and then eat as much as we could find as much as we could grow as much as we could catch that's actually how our body is built now we are adaptable that is fabulous about all life we are adaptable but we adapt to our environment so it's this interaction that I really want you to think about as age increases activity decreases so determinant of weight gain and children back to this question you know we know from the CDC about this epidemic and adults does that impact children well there are many studies to show that parental obesity is a key determinant of obesity risk and children I'm going to show you some data from our studies that really solidify that in a Latino population and some of it will be genetics shared genetics and some of it will be shared environmental risk factors such as maternal intake of sweetened beverages high calorie snack foods and takeout meals all associated with children's intake of food we eat what's in the pantry if we're home we eat what we can afford when we're out there are early life determinants of obesity such as breastfeeding now many studies to reconfirm that breastfeeding does decrease the risk of later obesity in very small amounts so it's not confounded by socio-cultural factors some studies show that an increased duration of breastfeeding is associated with a lower risk of obesity a slightly lower risk less than five percent rapid infant weight gain studies out just from here and a half ago lunasin at all in JAMA showed rapid infant weight gain that predicts childhood overweight at four years of age so back to this notion of viscous kind of a chronic process and what contributes to the chronicity of this problem so we now look at the rate of rise of how fast you're gaining your weight in infancy because then ocean is if you can control that to have a normal way to rise it appears to be associated with better health outcomes when you're older more determinants of weight gain in children we know poverty is a strong risk factor for childhood obesity so in a study of Baltimore homeless shelters eighteen percent of children were were overweight and twenty-three percent were obese these that was an old study so I've changed it to reflect the CDC definition that I gave you and none of the children our parents were underweight based on data from n Haynes 1999 to two thousand and two children from food-insecure households meaning you don't know where and when your next meal will be coming from are likely to have a higher BMI in fact obesity is the most visible form of malnutrition that we have I'm rereading a book called let them eat promises which is about malnutrition in America in the 60s it followed exactly the same pattern that I showed you from the CDC map started in the southeast spread across the country and where it started is where obesity started and how it spread so critical elements for efficacious pediatric obesity interventions this is from reports from the American Heart Association the American Dietetic Association and meta-analyses looking at what are some promising interventions in pediatric obesity well they appear to include these four components nutrition education physical activity education behavior modification and parent training we're going to talk about what that actually means and what that actually looks like obesity and diabetes we know that these this is linked and in fact Olshansky in the New England Journal of Medicine about four years ago did a study looking at the data and extrapolating if we continue on our trajectory that thirty to forty percent of children born in 2000 could go on to develop type 2 diabetes but just because you're obese doesn't mean you're at risk for diabetes in fact we have a better understanding now that we realize that the largest endocrine organ appears to be our adipose tissue depending on how much adipose tissue you have that the add of the kinds that are released from your adipose tissue leads to an inflammatory pathway that appears to be associated with that onset of obesity and it's visceral adiposity around your waist where it appears that you have more active at of kinds at work so those people who have generalized adiposity actually have fairly good outcomes those people that have visceral adiposity tend to have worse outcomes moving into adolescence and adulthood so now I'm just trying to focus its on Latinos in this issue what we notice about Latinos is that they tend to have more visceral adiposity when they gain weight they also have more and seventy-four percent of women having little or no leisure time physical activity and we know physical activity is what is linked with insulin resistance so that mechanism of insulin resistance leading us to diabetes so the more physically active you are regardless of whether you change your body mass index we know the more insulin sensitive you become and the less physical activity you have the less insulin sensitive you become you're more at risk for diabetes so it appears that our Latino population has these two risk factors this that when they become obese it's mostly visceral adiposity and they also have less time spent in physical activity now I don't really have time to elucidate the mechanisms that we believe are at work here there multiple and it's evolving and every day I read a new article that i can add into my talk so stay tuned but i do want to give you a sense of these contributing factors so we save my visceral adiposity and latinos that must have to do with your genetics which there's got to be the part of your body that says where your fat is going to be distributed that mechanism in that code that has to do with your genetics right so there have been genome-wide Association studies and case control studies that reveal that genes are associated with obesity and just to clarify for this audience I'm talking about common forms of obesity not the rare forms of obesity the number of risk alleles it appears is highly correlated with average BMI for common forms of obesity this was a this is a genome-wide Association study with more than 30,000 adults and it was looking in European populations the main thing that I wanted you to notice and dr.

Willa was just here interviewing we hope that she'll be able to come and join us here this was was from nature genetics 2009 that we see that for the eight snips that they identified at that time and now they're 34 one year later that you can see that the more alleles that you have each snip has two alleles they looked at eight so this is a risk score factor that takes you from zero to 16 in terms of your risk with only these eight single nucleotide polymorphisms these are teeny tiny proteins so you can see though with this 30,000 population-wide based study you can see that the the higher your allelic risk score for these eight snips the higher the likelihood that you would be obese that your BMI increases in a clinically significant way it's because of this paper that we collected saliva in the study that I'm about to present to you but we know genetics can't tell us the whole story and in fact when you break out the contributing percentage of genetics to common forms of obesity it appears to be quite small 1 2 percent of the variability for obesity so it plays a role but it doesn't appear to play the most prominent center role it plays an important role in the whole scope of other contributing factors so when we look at causes of preventable mortality in general here's our typical breakdown that forty percent of causes of preventable mortality is behavioral typically thirty percent is genetic fifteen percent social or socio-cultural ten percent healthcare shortfalls and the rest environmental toxins so from jama this is a while ago from nineteen ninety three so i think it would be interesting for us as we continue to gather more data to try to understand the degree of contribution that each of these elements has towards these common forms of obesity to help guide us and understand what interventions will be effective it's because of this complexity that our team looks at applying an ecological model when we develop interventions so raise your hand if you've heard of an ecologic model great the world health organization uses this model and the way that we look at this in terms of pediatrics is that you've got the level of the child and contributing factors from the level of the child the level of the family and that contributes to not only the family but to the child what's happening in the community and how that impacts family and child and then the larger society and so most of our studies we try to cross as many of these levels as possible as we're trying to work towards developing impactful interventions this comes from the institute of medicine's view so we're pausing and summarizing before we move now into interventions so the Institute of Medicine has been looking at this issue for this decade and they've been recognizing that pediatric obesity looms as a huge public health threat as you can see not just in childhood but as it persists into adulthood and and looking at the fact that this is you might notice the ecologic model just laid out slightly differently all of these levels contributing back to our energy balance equation because it's when this energy balance equation is out of whack and you have more calories in and fewer calories out that you get this energy imbalance that leads to the obese child who then typically will go on to become an obese adolescent and an obese adult and I've spoken at the level of the child and genetics the level of the family and shared environment this is really looking at the social level so we know from Christakis and Fowler in the New England Journal of Medicine 2007 that it appears that weight gain in one person is associated with weight gain in another that a person's person's chances of becoming obese is increased by 57% if your good friend is also obese by forty percent if your sibling is obese and thirty-seven percent of your spouse is obese I'm fascinated actually buy this this is I thought it would be reversed to tell you the truth but this is only for adults in a subsample from the Framingham study so it's a very particular population there were very few Latinos in the framingham study and it just really i think asks us to consider is obesity socially contagious this really says the same thing okay now we're going to say well it seems to lead to poor outcomes could social contagion be used to lead to positive outcomes well same group showed that smoking cessation behavior by an index patient decreased a person's chances of smoking by 67% now here's direction that made more sense if your spouse quit smoking you are more likely to quit smoking twenty-five percent if your siblings were likely to stop smoking thirty-six percent for friends and thirty-four percent among co-workers so it appears that these effects are due to interpersonal relationship rather than geographic distance and effects again from the Framingham subsample that we're looking at here appear to be mitigated by higher educational levels so what about Latinos what about newer immigrant populations what about lower acculturation what about lower educational levels so we were asking all of those questions now that you have this background and the first study that we did is an NIH study called tipping the energy balance in Latino children and none of our patients actually like that that title so we called it ensues Marquez ninos y Padres juntos so which is on your mark used to be on your mark get set go but we shortened it parents and children together recognizing the strong impact of parent on child and we were interested in this idea of how will we use or how could we use a recreation center as an extension of the doctor's office to impact BMI for overweight latino adolescence now we started with adolescents because we were optimistic we thought let's intervene at an age where the child has decision-making capabilities and is interacting with their parents in a different way that they're really an interactive dyad with independent decision-making also there were many previously validated surveys that we could use as well so that's why we focused on adolescence this study was a randomized controlled trial we enrolled 106 parent-child dyads the age of the child was between eight and 11 there was a BMI prerequisite of greater than or equal to the 85th percentile and they all received care at a common clinic where eighty percent of our patients were Latino so then parent-child diets were randomized to either the intervention group or the control group the intervention group was six we call them on the move clinics your first clinic happened in your doctor's office and the next five monthly in your recreation center we didn't talk about being active we were active that was part of the expectation of a healthy visit and our partner was the YWCA this is right at the time when I was transitioning from being at Wake Forest in North Carolina here so I flew back and forth to finish this study with this population fabulous partner the YWCA full service recreational community of community-based YWCA and the control group they had two on the move clinics but they were clinic-based now we did all of our studies are mixed methods before we launched a randomized control trial we do a lot of qualitative work up front we need to determine what's the right dose what's the likelihood that families could attend a monthly session a biweekly session daily session what topics are appealing what topics are low-cost and translate into immediate action so we held three focus groups before we decided final process and content and that included the control group as well because of that we enhanced our care for our control group we provided a clinic-based setting in the control group where it was the prepared proactive discussion everybody filled out what are they eating how active are they before they walked into the doctor's office the physician reviewed everything ahead of time so they could create a targeted conversation and this was then followed by a 45-minute group health educator session where families were together there's that social influence part that was our control group so we call that enhanced standard of care so what happened in the intervention condition for visit one provider problem focus visit we only looked at activity because when you think of a recreation center you think activity we also from our from our discussions with families really heard loud and clear that play was a natural fit for children and eating their broccoli wasn't so we wanted to get started with something where they could be successful and that was activity we used applications that brief principles of motivational interviewing and we used a reciprocal parent-child contract to set goals all based on the latest evidence from Len Epstein and his group and longitudinal trials this was then followed by a 45-minute group health education session focused on functional activity not expensive sign up for gold gyms kind of activity the next two to six visits were 20 minutes skills building 30 minutes group activity 10 minutes of contracting with follow-up monthly phone calls over six months already mentioned to you what the control condition was now I just wanted to let you know who who were these people that participated so this is just baseline demographic characteristics because of our eligibility criteria the age which should have been between eight and 11 and it was about forty five percent were males for the child the BMI was this is the absolute BMI for children 25 that is that is overweight that is that is overweight for an adult when we looked at BMI percentile were at the 94th percentile and what we noticed was that the majority of people in our study were not just overweight they were obese we initially tried to make this even and we couldn't do it we couldn't find enough Latino pre-adolescents who were merely overweight and then we looked at media use and it was fairly similar to what we know nationally average me the use of 3.1 hours a day of screen time but pretty large standard deviation of two point six hours for the adults they were average age of 33 very low acculturation mostly Spanish speaking with a friends family we used a version of the short acculturation scale most of them of the parents that participated were mothers most of whom had low maternal education with the majority not having completed high school and their BMI absolute BMI of 33 greater than 30 morbidly obese this was not an eligibility criteria this is what we found so briefly because I'm aware of time from baseline to six months this study occurred over the duration of a six month period of time we found for all comers intervention and control group participants that forty seven percent of the children that participated lost weight now not a lot this is BMI change this is not wait changed but they lost weight consistently now typically what we see in a population where there is no intervention and I'll show you that coming soon is that BMI continues to rise over time so we could consider this as a stabilization of BMI and sixty-three percent of parents that participated lost weight losing weight was not a goal of the study we never said the words losing weight we only focused on healthy lifestyles and being active with your children when we looked at our hierarchical regression modeling predicting child absolute BMI change and we chose that because our children were morbidly obese the majority of them that we and we looked at the dyads who completed baseline to six months that was a 68% retention for community-based study which is right on par a little bit better than most community-based studies and just to notice this really surprised us our control group was more effective than our intervention group and we notice that the child's age impacts it the older the child the more likely their BM I would increase the younger the child the more likely it would decrease over that period of time and we also noted that your baseline BMI is highly predictive of your later BMI that's very consistent with the data that I presented earlier this morning so what about this parent-child interaction is there a parent-child effect at the parent is obese and apparent losses or gains weight with their child so we looked at all 72 parent-child dyads so let me explain to you what this is this is BMI change for the adult on this axis so you're either losing BMI or you're gaining it over time an absolute BMI change for the child's you're either losing it over time or you're gaining it over time each of them are dyadic and if you're a plus you're a girl and if your star you're a boy so just to show you that in general if I drew a line here there was a correlation that was significant that if your parent lost weight that you would lose weight this is I'm showing you the outliers to tell you the story which is this particular parent lost 13 BMI points in six months we never talked about losing weight and that child lost nine BMI points over six months over here this parent gained about five BMI points and this child gained about to BMI point they're related this is an important finding that hadn't been reported about parent-child diets how they interact how they affect each other and if this holds true for lower education Latino populations so our study conclusion from this trial was for overweight Latino pre-adolescents BMI change over time appears to be correlated with change in parental BMI that a clinic based intervention which shocked us that was completely the opposite of our hypothesis with a group education component appeared to be more effective than a recreation center based intervention and that interventions in this epidemic the disproportionally encyclia should focus on parent-child diets it also showed us that if you wait until your pre-adolescents it's too late for prevention which is why we moved on to this study salud con la familia which means health with the family the research question was how there's a lifestyle intervention of fate affect weight trajectories in Latino preschoolers and we were very fortunate to be funded by the state of Tennessee as well as the vanderbilt institute of clinical and translational research and we've just received an extension grant from the state as well this wasn't on purpose but we knew we wanted to enroll at least a hundred parent-child I ads we enrolled 106 but this time we march the age back to preschoolers ages two to five and we randomize them either to an intervention or control group now the intervention group was weekly because we believe I haven't tossed out the notion that a recreation center based program fails and we should never do it it just really made me think about the dose effect of monthly recreation programs and in fact what has come out since we did our first trial was a meta-analysis that was published just a year ago to say that your dose has to be at least weekly for at least three months to show in effect and that influenced how we organized this so this was weekly for three months 90-minute skills building modules that really used the notion of building new social networks the control group was three sessions 60 minutes had nothing to do with obesity it was about school readiness so the intervention included things like center and tour membership we learned that a lot of families didn't know how to use their recreation center even though it was free and accessible to them within five miles walking distance of their home we worked on parenting and teaching appropriate limit setting skills building and dyadic nutrition and physical activity the control group include a live library tour membership everybody got a library card skills for reading with children and strategies for bilingual success we collected a lot of objective variables we also learned that from ends who's Marcus we had a lot of self-reported variables for an seuss Marcus for this we collected BMI body composition using a bia or bioelectrical impedance and waist circumference because of visceral adiposity as I discussed with you we looked at parenting practice with the child feeding questionnaire and parental support of child's physical activity level we looked at self-report for food intake for physical activity sleep and screen time and then we also use actigraphy so they all raise your hand if you know what an accelerometer is it looks kind of like a little watch we use the kind that attached to the waist because this kind of expenditure for the wii is different than this kind of expenditure so we that's why we decided to use this waist based accelerometry both parent and child wore this for seven days we also did genetic screening based on the data that I showed you so I can tell you that as of yesterday we just finalized sassa fication of our data set which means everything is just right conditions are perfect for us to now begin our final analysis but to prepare for this talk today I thought I'd give you a peek with our preliminary analysis ninety-five percent of our parent participants were mother mothers eighty-nine percent of children were born in the US while eighty-three percent of parents were born in Mexico we are at that at-risk second generation eighty percent of parents spoke only Spanish at home there sash acculturation with one point to the scale is 0 to 4 4 as highly acculturated zero is poorly acculturated this is a low acculturation even though the majority of them had been in the country for ten years sixty-two percent had some high school and twenty one percent had some kind of graduate equivalent so just at baseline the main things I wanted you to notice we did not recruit overweight children and families that was not part of our eligibility criteria all comers coming to a recreation center working on healthy lifestyles and this is what we found we found that BMI for age percentile the mean was sixty-nine percent that's good rights less than the 85th percentile for parents we saw that the mean BMI see how close that mean BMI is to obese certainly overweight we looked at baselines results for how active were these kids at the beginning of the study before we did anything so this is the accelerometry data that i mentioned to you and i'm just looking at how often are you sedentary so sedentary means you guys are doing a pretty good job of being sedentary right right you're not asleep I hope right that sleep looks different on acting goofy but you're sedentary and many of you aren't even fidgeting well done but fidgeting burns calories so please feel free so what I want you to notice here that really surprised us is that we saw that of the wearing time when they were awake over seven day period of time during that awake period eighty-two percent of their awake period was spent being absolutely sedentary like you are right now but here's the shock these are preschoolers anybody have preschoolers and drives right seventy percent of their awake time absolutely sedentary this is contrary to childhood it's just not what a toddler does right so now just a peek into what does it look like we're finding over time okay and wait for the final results but I wanted to give you just a taste of it I mentioned that it looked like our mean BMI percentile was good for this population when we looked at what percent actually had a BMI greater than or equal to the 85th percentile but less than 95th percentile forty-one percent remember the data that I showed you from the CDC that said it's supposed to be 25 to 27 percent those that participated in the intervention group were twice as likely to change their weight category from overweight to normal in three months than those in the control condition who continued to increase their BMI over just a three-month period of time what could this mean now huge grain of salt please this is preliminary data I'll come back with my final data we've got significant positive correlations between parent and child in activity over the course of the day in order to increase the activity level of Latino preschool aged children parents are critical right there critical in setting normative expectations and family based community interventions appear promising to change early BMI trajectories as long as that dose is powerful enough it's got to be a weekly dose for at least three months this month were bringing these same families back and we're going to collect a third point to see what happened now one year after the study started pediatric obesity if not curtailed could lead to one in three adults with type 2 diabetes in the future and the possibility that children will die before their parents Latinos have a higher risk and other ethnicities and interventions focused on parent-child dyads clinic counseling for already overweight obesity and community-based interventions and preschoolers show promise for addressing pediatric obesity in Latino populations I just wanted to thank my team here's my North Carolina team from and since Marcus and here is my solution la familia team here in Nashville none of this is possible without a team it takes a village to do a research project so thank you everybody I'm open for a few questions if you're able to stay 10 priests children who attend preschool and their activity level and their weight like head start yeah well it's interesting you mention that because we are working Joan Randall is really leading this effort for our task force or Tennessee obesity task force nicknamed tots and and Joan we're very fortunate to have leading our statewide plan for the CDC and preschools and schools are a huge part of that there's tremendous inconsistency there are recommended standards there is no reinforcement of standards and people human beings were good at sort of adapting to the easiest path possible so i would say that there are voluntary standards and a lot of inconsistency much room for growth here given what you said about weight being associated with prosperity in this culture i wondered what the reactions were of the families who lost weight during that three-month period great well actually that the whole concept of gordito and gordita and prosperity that went right into our modules for discussions so that what we did was we said talk let's talk about this how do you know your child is healthy and we talked about what gordito means culturally versus what does it mean for your health we created cognitive dissonance that led to a lot of discussion and people started to understand health first rather than that visible sense of gordito now my question our team is wondering if we've got staying power what happens when you're not constantly in this group this social group that we've put together creating new social networks and will data coming forth about that to show you that these kinds of interventions do create new social networks and that data is just being run right now by dr.

Sabina gazelle that what we don't know is does it sustained over time and that's why we're delighted that the state has given us additional funding because we need to ask that question other questions did you say something about the father's involved in the sample great so you know here's something that's interesting first in our North Carolina study we had very few fathers there was one that was involved and it's because he had been laid off of work and and he actually participated but felt slightly ashamed initially that he was there because that's mothers work and there's some really very clear lines at this point with our Mexican American families that we've been working with but what we found in the Saluki lithonia study which of course was done right in the middle of an economic recession and people were losing their jobs anyway is that the mothers would start to come if they liked it the next session they brought the fathers and we've actually tracked this we didn't intend this at all we just started noticing it and then if they really liked it they would bring their cousins and maybe their neighbors so I we actually have those as processed data that first you have to prove that it's worthwhile secondly you have to prove that it goes beyond the mother so and I think we're going to need to have some debriefing interviews with fathers to better understand their role we do we do know that you know fathers often control the money and they can say you know fix me this for dinner whether it's healthy or not so there's a lot of decision-making power there and it will be important but paradoxically we find that it's change in mothers over time and if they're losing weight or not that seems to be correlated with change in their child thank you thanks for that wonderful presentation I have to ask sitting in this building do you know if there were children with disabilities in your groups either in North Carolina or here they they did not have they did not have disabilities that that I knew of that were obvious or knew of and we didn't ask about that either I think we have one more question once a week is a pretty intensive intervention and I was wondering where most of the families able to come to most of the sessions and to stick with it through that time or was that difficult for the families to do this is the challenge of community-based work community-based work it's about prevention is hugely challenging for retention we spend a lot of time on recruitment and retention for this kind of work and we found that we had a sixty-six percent retention which is consistent with community-based trials over time and those people that we lost over time some of them were had to move out of the state and several lost their jobs and lost the ability to continue in the study because then comes Maslow's hierarchy of need and where is this study fit into what I need to do so we track specifically why we lost people over time we always do that but it was fairly consisted I'm surprised to say with the other study it's important retention is just crucial for us to make sure we're answering our questions thank you everybody for this opportunity you

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