This document discusses challenges with childhood obesity interventions and measuring dietary intake. It notes that while simple messages to "eat less and exercise more" are commonly prescribed, studies show such interventions have limited effectiveness. Methodological issues make accurately assessing dietary intake and determining the true causes of obesity difficult. The document examines a variety of factors potentially contributing to obesity, from food marketing and lack of activity to genetics and environmental chemicals. It emphasizes the complexity of obesity's causes and questions the reliability of common measures like BMI and self-reported diets.

1. Fit Kids
Why “Exercise More, Eat Less”
Is Not Enough
Bonnie Y. Modugno, MS, RD
www.muchmorethanfood.com

2. State of the Nation
• Change in 70
incidence of 60
obesity between 50
1970 and 2000 40
1970's
30 2000
20
10
0
Adult CH AD
US Dept of Health and Human Services, NCHS, Prevalence of overweight and obesity among adults and
adolescents, 1999-2000.

3. Treating Obesity
• Eat less
• Exercise more
Calories in < Calories out = Weight Loss

4. Interventions for preventing
obesity in children
• 22 RCT or CCT published after 1990
• Results of 12 short term trials
– Two of four short-term studies aimed to increase
physical activity levels resulted in minor reductions
in overweight
– The other eight studies included advice on diet and
physical activity, but none had a significant impact.
Summerbell CD, Waters E, Edmunds L, Kelly SAM, Brown T, Campbell KJ.
Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD001871.

5. Treatment of Pediatric Obesity:
A Systematic Review
and Meta-Analysis of 61 Randomized Trials
• Results
– Limited evidence supports the short-term efficacy of
medications and lifestyle interventions
– The long-term efficacy and safety of pediatric
obesity treatments remain unclear
McGovern, et al. J Clin Endocrinol Metab 93: 4600–4605, 2008)

6. How good are the studies?
Methodological challenges
1. BMI
2. Dietary assessment
– Food frequency surveys
– 1-3 day food recalls
3. Dietary approach

7. Point: BMI
• BMI is an important indicator of overweight and
obesity in childhood and adolescence.
• When measurements are taken carefully and
compared with appropriate growth charts and
recommended cutoffs, BMI provides an excellent
indicator of overweight and obesity sufficient for most
clinical, screening, and surveillance purposes.
Himes. Pediatrics Vol. 124 No. Supplement 1 September 1, 2009 pp. S3
-S22

8. Counterpoint: BMI
• BMI is a poor surrogate measure of adiposity
• Compared w/ dual energy x-ray absorptiometry,
excessive body fat was found in
• 77% of children w/ BMI > 95th %
• 20% of children w/ BMI between 85-94th %
– 50% of children have “moderate” adiposity
– 30% of children have “normal” body fat stores
Freedman, et al. Classification of Body Fatness by Body Mass Index–for-Age
Categories Among Children Arch Pediatr Adolesc Med. 2009;163(9):805-811.

9. BMI BMI
32.5 30.6

10. What are we measuring?

11. What is the purpose of measuring?
• Body size ?
– Height/weight
– BMI
– Body composition
• Health ?

12. Reliability of Dietary Intake
• Review of 4 prospective
cohort studies
The Degree of Misreporting of Dietary Intake
McCrory, et al. Public Health Nutrition:
5(6A), 873–882 , 2002.

13. What are we eating?
• Weekly food costs
• N. Carolina, USA
• $341.98
Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005.

14. What are we eating?
• Weekly food costs
• California, USA
• $159.18
Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005

15. What are we eating?
• Weekly food costs
• Mexico
• $189.09

16. What are we eating?
• Weekly food costs
• Guatemala
• $76.70

17. USDA Food Disappearance Data

18. Cost of food 1985-2000
Soft Drinks
Fats/Oils
Eggs
Sugar/Sweets
Poultry
% Increase Red Meat
Dairy
Cereal/Bakery
Fish
Fr and Veg
Fr. Fruit and Veg
0 50 100 150
USDA Data 2002

19. How Much Does 100 Calories Cost?
90
Soda
80
• Cost in cents Bread
70
60 Potato
• Vegetables and fruits cost chips
more per calorie 50 Cookies
40
Licorice
• Food costs surveyed 30
Orange
Sept/2011 20
10 Apple
0 Carrots
100 Calories

20. Childhood Obesity
by State Assembly District
http://healthyamericans.org/reports/obesity2005/CaliforniaEndowmentReport.pdf

21. Antidote to a Food Desert/Food Swamp:
More Full Service Supermarkets

22. Are Supermarkets the Answer?

23. Where are we purchasing our food?
70
60
50
40
30
20
10 1972
0 2008
www.usda.ers.usda.gov/Briefing/CPIFoodandExpenditures/Data

24. Calories on the Menu
Crispy Calimari w/…
Pork Milanese
Personal Meat Lover's…
Chicken Strips w/ fries…
Large Tuna Melt
Sunrise Quesadilla… Fat Kcal
Smokin' Q 3 Pack Burger… Calories
Granny's Country Omelet
Jalapeno Smokehouse…
Ribs and More Ribs
0 500 1000 1500 2000 2500
http://www.nowpublic.com/health/forbes-top-10-most-fattening-chain-restaurant-meals-calorie-menu

25. What about calories?
• N = 253 9-10 y/o 2500
**living in/near Provo, Utah 2000
Leanest
1500
1000 Moderate
500 Fattest
0
Kcal
Tucker, et al. ADAJ, 1997; (97) 9

26. What about the source of calories?
300 80
250 70
60
200 Leanest Leanest
50
150 40
Moderate Moderate
100 30
50 Fattest 20 Fattest
10
0
CHO (gm) 0
Fat (gm)
Tucker, et al. ADAJ, 1997; (97) 9

27. Candy Consumers (n = 3,458)
vs. Non-Consumers (n=7,724)
80
70
60
T. Candy -Cons
50 T. Candy- NC
40 Choc-Cons.
30 Choc-NC
20 Sugar-Cons
10 Sugar-NC
0
Weight (kg) BMI Waist Circ. (cm)
http://www.eurekalert.org/pub_releases/2011-06/fl-nss062811.php
http://www.foodandnutritionresearch.net/index.php/fnr/article/view/5794/8675

28. Candy Consumers (n = 3,458)
vs. Non-Consumers (n=7,724)
2400
2300
T. Candy -Cons
2200
T. Candy- NC
2100 Choc-Cons.
Choc-NC
2000
Sugar-Cons
1900 Sugar-NC
1800
Calories
http://www.foodandnutritionresearch.net/index.php/fnr/article/view/5794/8675

29. Food Composition and Insulin
* *
0
-1
-2
Weight change (kg)
-3
-4
-5 High CHO
-6
Low CHO
-7
-8
-9
-10
Low Insulin High Insulin
Secretor Secretor
Pittas, A. et al. Diabetes Care 28 (12): December 2005

30. Changes
over time
for study
outcomes
Ebbeling, C. B. et al. Arch Pediatr Adolesc Med 2003;157:773-779.
Copyright restrictions may apply.

31. Effects of Meal High in Carbohydrate
on Satiety in Pre-pubertal Children
NW
Obese
Lomenick J P et al. JCEM 2009;94:4463-4471
©2009 by Endocrine Society

32. Effects of Meal High in Protein
on Satiety in Pre-pubertal Children
NW
Obese
NW Pre-adol.
Obese Pre-adol.
Lomenick J P et al. JCEM 2009;94:4463-4471
©2009 by Endocrine Society

33. What starts the day?

34. Ten Putative Contributors
to the Obesity Epidemic
• Food marketing • Maternal age
practices • Assortative mating
• Physical activity • Sleep debt
• Infections • Endocrine disruptors
• Perinatal epigenetic • Pharmaceutical
factors iatrogenesis
– maternal obesity • Ambient temperature
– over/undernutrition
– hyperinsulinemia
Critical Reviews in Food Science and Nutrition 49(10) 868-913 (2009)

35. Ten Putative Contributors
to the Obesity Epidemic
• Food marketing • Maternal age
practices • Assortative mating
• Physical activity • Sleep debt
• Infections • Endocrine disruptors
• Perinatal epigenetic • Pharmaceutical
factors iatrogenesis
– maternal obesity
• Ambient temperature
– over/undernutrition
– hyperinsulinemia
Critical Reviews in Food Science and Nutrition 49(10) 868-913 (2009)

36. Perinatal Epigenetic Factors
• Before pregnancy health status
– Nutrient intake, calorie intake
– Relative insulin sensitivity
– Activity level, stress management
• Perinatal nutrition status
– Diet & activity
– Glucose tolerance
– Total and rate of weight gain
• Nutrition status infant
– Birth weight, rate of weight gain
– Breast v. Bottle feeding

37. Genetic Traits Impact Food Intake
• Up to 69% of eating behaviors may be genetically determined
– Response to internal satiety cues
– Response to taste or smell of food
– Sensitivity to rewards/reinforcement for eating preferred foods
– Food preferences
• Parental monitoring of food intake
– is more result of child obesity,
not an antecedent
Stang and Loth. ADAJ:111(9) 1301-1305

38. Iatrogenic Medications for Kids
• Weight gain is possible with many medications
– Psychoactive meds
• Anti-psychotics
• Mood stabilizers
• Antidepressants
– Diabetes Meds
• Insulin, Sulfonureas
– Steroids
• Allergies, asthma,
• Oral birth control

39. PSYCHOACTIVE DRUGS:
Dietary Guidance
• Use portion control for all food at meals and snacks
• Use more healthy food choices (example - fresh fruits
and vegetables for snacks)
• Limit snacks and junk food
• Substitute high calorie for lower calorie snacks
(example – pretzels instead of chips/nuts)
• Drink several large glasses (or bottles) of water
throughout the day
• Limit sugar sweetened beverages

40. Endocrine Disruptors (POPs): Sources & Pathways to Human Exposures
SOURCES
TRANSPORT DEPOSITION FOOD SUPPLY
Industrial
Processes
Combustion
Runoff
Erosion
Direct
Discharge
Courtesy of Dr. Linda Birnbaum, PhD, Director of Toxicology, EPA (adapt)

41. Food System–Related Environmental Chemicals
Detectable In Pregnant Women In The United
States, 2003–04.
Sutton P et al. Health Aff 2011;30:888-897
©2011 by Project HOPE - The People-to-People Health Foundation, Inc.

42. Endocrine Disruptors, POP’s
 Impaired neurological growth and function
 Learning disabilities
 Autism
 Impaired glucose tolerance
 Obesity, Diabetes
 Cardio -Metabolic Syndrome
 Cancer
 Impaired thyroid function
 Obesity
 Cancer
 Impaired fertility; reproduction
 PCOS
 Low Testosterone (males)

43. Pesticides: Atrazine
• Obesity epidemic is most rampant in Mississippi valley watershed
Kwak, S. H., Park, K. S., Lee, K.-U. and Lee, H. K. (2010),
Mitochondrial metabolism and diabetes. Journal of Diabetes
Investigation, 1: 161–169.

44. State of the California
http://healthyamericans.org/reports/obesity2005/CaliforniaEndowmentReport.pdf

45. Dietary Guidelines for Fit Kids
• Eat balanced meals and snacks
– Enough protein
– Carbohydrates preferentially from whole foods, mostly
produce
– Enough healthy fats
CHO PRO + PRO +CHO
CHO w/ FAT
0 1 2 3 4 5 6
SATIETY --TIME AFTER EATING (hours)

46. Dietary Guidelines for Fit Kids
• Eat regular meals, snacks through the day
• Avoid getting over hungry
Starving Just Enough Full Stuffed
Still Hungry Satisfied Overfull

47. Dietary Guidelines for Fit Kids
• Eat when your are hungry; stop when your hunger is
gone
• Self regulation
• Resilience

48. Dietary Guidelines for Fit Kids
• Health at Every Size
– Focus on behavior,
not weight or BMI
– Body size should not a litmus for
what someone gets to eat
– We need to teach all of our
children how to survive
abundance

49. Fit Kids
Q&A
Thank You
Bonnie Y. Modugno, MS, RD
www.muchmorethanfood.com