Sports Medicine

Are Current Health Care Practices Propagating Obesity in our Youth?

The Role of the Physician to Prescribe Solutions

Thomas M. Best, MD, PhD, FACSMThe Ohio State University

Improving People’s Livesthrough innovations in personalized health care

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

Dementia

Cardiovascular Diseases

Colon cancerDepression

Breast cancer

Type 2 diabetes

Pedersen BK. J.Physiology 2009

Exercise Deficit Disorder (EDD) in Youth

• Walker GA, Edwards NM, Stracciolini A, Faigenbaum AD, Myer GD. The Use of Exercise-specific V Codes and Reimbursement at a Large Pediatric Medical Center. AMSSM 2013.

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.

Lecture Overview

• Discuss the paradox that exists in youth fitness and sports today.

• Review the wide ranging benefits of PA in kids and implications of an inactive youth population.

• Talk about current messaging on youth health behaviors

• Discuss the role of the physician and healthcare systems in assessing and prescribing exercise.

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.

• 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!

Youth Fitness and Sports Paradox

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

Benefits of Physical Activity in Kids

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. 6:406-423Sabo et al. J Adolesc Health 1999;25:207-16

Fitness And Stanford Achievement Test 9th Ed SAT-9 and Fitnessgram Results

• Fitnessgram test:– 1. Aerobic Capacity– 2. Body Composition (% of body fat)– 3. Abdominal Strength and Endurance– 4. Trunk Strength and Flexibility– 5. Upper Body Strength and Endurance– 6. Overall Flexibility

353,000 Students

Number of Fitness Standards Achieved

Source: California Dept. of Education Study, December 10, 2002

10

20

30

40

50

60

70

80

1 2 3 4 5 6

Grade 5SAT 9 and Physical Fitness

Reading Mathematics

0

29

3632

4036

4540

5046

58 55

71

SAT

9 Pe

rcen

tile

0

10

20

30

40

50

60

70

1 2 3 4 5 6

SAT

9 Pe

rcen

tile

322,000 Students

Source: California Dept. of Education Study, December 10, 2002

Grade 7SAT 9 and Physical Fitness

26 2831 32 34 36

4144

5054

60

66Reading Mathematics

Number of Fitness Standards Achieved

279,000 Students

Reading Mathematics

21

35

24

38

28

43

31

51

37

58

45

67

Source: California Dept. of Education Study, December 10, 2002

Grade 9SAT 9 and Physical Fitness

0

10

20

30

40

50

60

70

SAT

9 Pe

rcen

tile

1 2 3 4 5 6Number of Fitness Standards Achieved

300

310

320

330

340

350

360

370

380

0 1 2 3 4 5 6Number of Fitness Standards Achieved

CST

E-LA

Mat

h Sc

ore

Source: California Physical Fitness Test, 2004 Results, Calif. Dept. of Ed., April 2005

371,198 Students (203,726 NSLP and 167,472 Non-NSLP)

Socioeconomic Status** & Number of Fitness Standards 2004 CST* Scores in English- Grade 5

*California Standards Test**National School Lunch ProgramResults using math scores were consistent with those using English-Language Arts scores. Results for seventh- and ninth-grade students were consistent with those for fifth graders.

Non-NSLP NSLP

0% 10% 20% 30% 40% 50% 60% 70%

Strength Test

Flexibility Test

Pacer Test(Cardiovascular Fitness)

Paced Curl-Up

Push-Up

Modified Sit & Reach

Improvements in Fitnessgram ResultsPE 4 Life Program at 6 months

Woodland Elementary School, Kansas City PSDFall 2005 – Spring 2006, Grades 4 and 5

Fall 2005 Spring 200613.5 %21.6 %

16.5 %

12.7 %

12.4 %

4.5 %

19.4 %

28.1 %

31.1 %

59.6 %

3 %16 %

88%

60%

127%

207%

182%

433%

2004 - 20052005 - 2006

0 200 400 600 800 1000 1200 1400

Resulting Out-of-School

Suspension Days

Discipline Incidents Involving Violence

228

1177

392

94

Percent Reduction in Disciplinary IssuesPE 4 Life Program at 6 months

Woodland Elementary School, Kansas City PSD #33Fall 2005 – Spring 2006, Grades 4 and 5

59%

67%

Hillman CH et al. Med Sci Sports Exerc 2005; 37:1967

Fitness and Neurocognitive Functionin 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

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.

JAMA. 2008;300(3):295-305. doi:10.1001/jama.300.3.295

Kids exercise less as they get older

Girls weekend12.6 yrs

Boys weekday14.7 yrs

% of High School Students Meeting Guidelines

23.718.5

15.5 14.917.1

10.5

0

20

40

60

80

100

Total Female Male White Black Hispanic

Per

cent

* 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?

0

1000

2000

3000

4000

5000

6000

7000

8000

P.E. School Day OutsideSchool

BoysGirls

Morgan CF, et al (2003) Journal of Physical Education Recreation and Dance, 74(7), 33-38.

Step

s pe

r day

NHANESPrevalence of Overweight Youth Ages 2-19

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

Where will we find our future?

• Firemen• Police officers• Prison guards• Soldiers• Lifeguards• Construction

workers

“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.

2000

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Hysteria

• The world has now been sufficiently alerted to the global problem of obesity.

• Patients have been labeled and stigmatized.

• Assigned lots of blame.• Spent lots of money.• …and gotten nowhere.

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 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.

We need a new (and fresh) approach!

Death Rates by Fitness & BMI Categories

0

10

20

30

40

50

60

70

<27 27-30 >30

Deat

hs/1

0,00

0 M

Y

Barlow et al. Int J Obes 1995; 19:Suppl 4, S41-4

Low fitMod fitHigh fit

after adjustment for health status, smoking, glucose, cholesterol, & BP

Normal ObeseOverweight

• 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 we do?

Smith, Johnny 12 yrs M

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 moderate-vigorous 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?

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.

• Days per week in 153,746 kids age 12-17 (year ending 1/31/13):– 15.2% report 0 days per week.– 15.7% report 1-4 days per week.– 69.1% report 5 or more days/wk.

• Percent reporting >150 min mod exercise per week:– 77.5% in 12-17 yrs.– 34.5% in 18-64 yrs.– 29.8% in 65+ yrs.

EVS in Kids; Kaiser Permanente

“At Kaiser Permanente, we want you to Live Well, Be Well and THRIVE!”

Kaiser Permanente – “Kid Wisdom”

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.

• Mississippi State• U of Arizona• Georgia Tech• Lewis & Clark College• U of South Florida• Joliet College• Kentucky Wesleyan• Roanoke College• UCCS• Penn State• Slippery Rock

A Call-to-Action