secularsecular trends trends ooff obesityobesity iinn ... · osteoporosis, depression, stroke,...

01.05.2010

1

determinantsdeterminants ofof ((leisureleisure time) time) physicalphysical activityactivity andand in in consequenceconsequence

desirabledesirable policypolicy strategiesstrategies

determinantsdeterminants ofof ((leisureleisure time) time) physicalphysical activityactivity andand in in consequenceconsequence

desirabledesirable policypolicy strategiesstrategies

PD Dr. med. Susi Kriemler

FMH Pediatrics, FA Sports medicine

Swiss Tropical and Public Health Institute & Institute of Exercise and Health Science

University of Basel

SecularSecular trendstrends ofof obesityobesity in in adultsadultsin CHin CH

Staub 2010 BMC Public Health

BMI-shift:

Median shift 20.5 -> 22P90 shift 23 -> 27Overweight 1.5 ->23%

Jahr ∼∼∼∼1880Jahr 1930Jahre 2005-6

SecularSecular trendstrends ofof obesityobesity in in childrenchildren in CHin CH

7.4

19.90

0

5

10

15

20

25

Übergewicht Adipositas

%

1960-1965

1980-1990

2002

Zimmermann 04 Swiss Med Wkly

……whowho andand whatwhat isis decidingdeciding……

01.05.2010

2

overviewoverview

1. determinants of PA

• Children, adolescents, adults We don‘t let him play, but we won 4 games

by forfeit!

overviewoverview

2. what has been done to change PA habits

and what worked best

overview3. keys of an effective Public Health approach for policy

Social Ecological Model of Physical Activity

Davison & Birch 2001

PHYSICALACTIVITY

INDIVIDUALGender Age

Enjoyment

SOCIOCULTURAL

DIETARY

HABITS

SEDENTARY

BEHAVIOR

Beliefs Social capital

Physician

influence

Urban planning

policiesSocial support

friends

Social norms

Social isolation

Social support

family

Ethnicity

ENVIRONMENTAL/POLICY

Seasonality

Area-level SES

Crime rates &

neighborhood

safety

Walking/cycling tracks

Aesthetics of

environment

Active

transport

policies

Access to

recreational facilities

Someone to

be active with

Self-efficacy

Education

level SES

Barriers

Parental PA c

Peer & sibling

interactions c Children same

age live nearby c

Family rules

PA c

Cultural norms

Perceptions of

safety

Access to parks/

playgrounds

Connectivity of

streets

Topography

Organizational PA

policies

determinantsdeterminants ofof PAPA

11

The environment

Macro environment

Physicalenvironment

Individual behaviour

Economicalenvironment

Socio-culturalenvironment

Micro environment

Adapted from Egger&Swinburn 97 BMJ

1. 1. DeterminantsDeterminants ofof PA in PA in childrenchildrenandand adolescentsadolescents

• Reviews with separate results for children

(aged 3-12) and adolescents (aged 13-18)

• ∼200 studies reveiwed including ∼ 50

variables for children and adolescents

• % of univariate associations with

significant vs. non-significnat findings

• + clear evidence, +/- inconclusive, - no

evidence

Sallis 00 MSSE, van der Horst 07 MSSE

01.05.2010

3

DemographicDemographic//biologicalbiological variablesvariables

Children Adolescents

Males + Males

Parental education +/- Parental education +

Age, ethnicity - Age, ethnicity +/-

BMI/skinfolds - BMI, SES

single parent


Psychological variables Psychological variables andand PAPA


Self-efficacy +self-efficacy, attitude, goal

orientation/motivation

Intention, perceived barriers, sport competence +/-

Self perception, enjoyment, barriers

towards PA-

self-perception, perceivedbenefits, fun/enjoyment,

depression


SocialSocial//behaviouralbehavioural variables variables andand PAPA


Parental support +Parental and peer support ,

help from parents

+ Siblings PA

+ PE/school sports

Parental PA +/- Parental PA +/-

TV time - Smoking, TV time


Environmental variables Environmental variables andand PAPA


Program/facility access + Opportunities for PA

Time outdoors +

Perceived access tofacilities/play space/sporting

equipment-

Perceived access tofacilities/play

space/sporting equipment


CorrelatesCorrelates ofof PA in PA in adultsadults

Correlates Association

Personal Age, male, good health, lack of time

Psychological Intention, self-efficacy, perceived benefits

Environment Supportive physical environment:accessible facilities, presence of

sidewalks/bike paths, safe streets,

good lightening etc

Sherwood 00 Ann Rev Nutr, Pan 09 BMC PH, Dishman 85 Pub Heath Rep, NcNeill 06 Soc Sci Med, Sallis 02, Humpel 02 AJPM, Duncan 05 Int J Behav Nutr PA

CorrelatesCorrelates ofof PA in PA in adultsadults

Correlates Association

Social SES, social inequalities

Social support and networksSocial environment:

companionship, encouragement,

assistance from friends/family

members, tangible aid and servicefrom community,

advice/suggestions/information

from professionals

Sherwood 00 Ann Rev Nutr, Pan 09 BMC PH, Dishman 85 Pub Heath Rep, NcNeill 06 Soc Sci Med, Sallis 02, Humpel 02 AJPM, Duncan 05 Int J Behav Nutr PA

01.05.2010

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SummarySummary ofof PA PA correlatescorrelates

• Children: gender, self-efficacy, outdoors, parental PA, parental parental supportsupport

• Adolescents: gender, parental education,

attitude, self-efficacy, goal orientation/motivation, physicalphysical educationeducation//schoolschool sportssports participationparticipation,

familyfamily andand friendsfriends supportsupport

• Adults: age, gender, intention, self-efficacy, socialsocial supportsupport andand environmentenvironment, supportive

physicalphysical environmentenvironment

……somesome moremore toto considerconsider

100‘000 y

Homo sapiens

„„survivalsurvival ofofthethe fittest“fittest“

5-8‘000 y

Human societies

Economic successleads toto betterbettersurvivalsurvival

500-3‘000 y

HealthHealth promotionpromotionthroughthrough PAPA

• 776 first olympicgames

today

industrialisation

Elimination Elimination ofof PA PA asasstrategystrategy ofofsurvivalsurvival

-->>developmentdevelopmentofof chronicchronicdiseasedisease

Bouchard, Blair&Haskell 2007

….….moremore passive passive travellingtravelling ……lessless pedestrialpedestrial commutingcommuting

……moremore sedentarysedentary leisureleisure timetime ….….lessless domesticdomestic activityactivity

01.05.2010

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EffectEffect ofof changingchanging distributiondistribution ofofactivitiesactivities andand energyenergy costcost



2% positive energy balancecan lead to overweight

This is about 125 kJ/day or 15 min PA

abnormal reaction to a normal environment?

normal reaction to anabnormal environment?

Egger&Swinburn 97 BMJ

2. 2. whatwhat hashas beenbeen donedone toto changechange PA PA habitshabits andand whatwhat workedworked bestbest??

?

Intermediate

outcomes

health

outcomes

INTERVENTION AEROBIC CAPACITY

modifiable

determinants

PHYSIOLOGICAL MEASURES

(anaerobic capacity,

muscular strength,

endurance, HR, BP, capillary

density, stroke volume)

INFORMATION

BODY COMPOSITION

(muscle mass ↑, fat mass ↓)

BEHAVIOUR-SOCIAL

SKILL-BASED FITNESS

(balance, coordination)

ENVIRONMENT/POLICY

METABOLIC FITNESS

(bone density, lipid profile,

insulin, coagulation,

immunologic function)

MOOD

(anxiety, depression)

other modifiable determinants

(genetics, nutrition, co-

morbidities)

PA

BEHAVIOUR

Measures of

Mortality/Morbidity

and QoL

1°/2° prevention

suggested

osteoporosis,

depression, stroke,

PAVK, cholelithiasis

Measures of

Mortality/Morbidity

and QoL

1°/2° prevention

established

CHD, hypertension,

Diabetes, colon cancer,

falls with fracture,

health-related QoL

MODEL to look at INTERVENTION STUDIES

Kahn 02 Am J Prev Med

01.05.2010

6

Information Information approachesapproaches

• Designed to increase PA by providingprovidinginformationinformation necessary to motivate and enable

people to change their behaviour, as well as to

maintain change over time

• Focus on cognitive skills

• Use of primarilyprimarily educationaleducational approachesapproaches

• Interventions: point-of-decision prompts,

community-wide educational campaigns, mass media campains, classroom-based health

education

Kahn 02 Am J Prev Med

EffectivenessEffectiveness ofof informationinformation

InformationResults of intervention

trials

Point-of-decision prompts(placement of a sign)

recommended

Community-wide campaigns recommended

Mass media campaigns insufficient evidence

Classroom based healtheducation

insufficient evidence

www.thecommunityguide.org

InformationalInformational interventionintervention

� ‘point-of-decision’-signs on elevator doors

� motivational texts in staircases

� slim making mirrors in staircases

� routing of people to the stairs

Engbers 07 Prev Med

PointPoint--ofof--decisiondecision signssigns

Routing Motivational texts

1 mars = 27 min of stair walking

Engbers 07 Prev Med

Food Food labellinglabelling

• Food labelling: caloric values of products translated into number of minutes of a certain activity

1 orange = 55 Kcal

≈ 6.9 minutes cycling

1 mars = 270 Kcal

≈ 30 minutes stair walking

≈ 2.5 hours sitting in a meeting

Engbers 07 Prev Med

ResultsResults

• Effects generally modest

• Effects on LDL- and HDL-chol signficant in favour of the intervention group

• Effects higher in men and those with BMI<25

Engbers 07 Prev Med

01.05.2010

7

BehaviouralBehavioural andand socialsocial approachesapproaches

• Teaching widely applicable behaviouralbehavioural

managementmanagement skillsskills and by structuringstructuring thethe

socialsocial environmentenvironment ot provide support for

people trying to initiate or maintain

behavioural change


BehaviouralBehavioural//socialsocial interventionsinterventions

ChangeResults of intervention

trials

School-based PE recommended

Classroom health educationto reduce TV


Family-based social supportinterventions


Social support interventionsin communities

recommended

Individually-adapted healthbehaviour change

recommended


……oneone thoughtthought aboutabout thethe socialsocialsystemsystem....

• http://content.nejm.org/content/vol357/issue4/images/data/370/DC2/

NEJM_Christakis_370v1.swf

Chrisdakis 07 NEJM

The The closercloser thethe relationshiprelationship thethemoremore riskrisk

Chrisdakis 07 NEJM

SummarySummary

• A person‘s chance of becoming obese

increased

• by 57% if he/she had a friend who became

obese

• by 40% with an adult obese siblings

• by 37% with an obese spouse

A A behaviouralbehavioural//socialsocialinterventionintervention thatthat worksworks

• We therefore implemented a school-based PA intervention aiming at

• ↑ PA (accelerometry)

• ↑ aerobic fitness (shuttle run test)

• ↑ quality of life (child health questionnaire)

• ↑ percent body fat (skinfolds)

• ↓ a cardiovascular risk score (BP, waist circumference, HDL-cholesterol, triglycerides, glucose)

• Use of a behavioral and social approach by focussing

on increasing PA by structuring the social environment (school)

Zahner,Puder&Kriemler BMC Public Health 06

01.05.2010

8

KISS KISS populationpopulation

• Cluster-randomized, controlled trial

• 2 provinces (ca 10% ofSwiss population)

• N=504, 28 classes

• 1st and 5th grade

• equally distributed rural-urban

• 10-30% migrants

Zahner,Puder&Kriemler BMC Public Health 06

KISS KISS interventionintervention (1 (1 schoolyearschoolyear))

• Daily physical education (3+2 lessons) withcompensation of 2 academic lessons

• Short activity breaks during academic lessons

• Physical activity home work

• Play tools during recess

• Education of classroom teachers and parents

Dartfit

Short PA Short PA breaksbreaks PAPA homeworkhomework

Playtools Playtools forfor recessrecess

Cleven - Becker Foundation

-0,3

-0,2

-0,1

0,0

0,1

0,2

Deltas z-Score

-12

-7

-2

3

8

ResultsResults

Zahner&Kriemler BMC Public Health 06, Kriemler&Zahner 10 BMJ

28 classes (n=502)

ShuttlerunCardiovascular

Risk ScoreSum of 4 skinfolds

MVPA in school&whole day)

Qualityof life

* ***

RCT [15360785]RCT [15360785]

Intervention

Controls

**

Del

tas

skin

fold

s (m

m),

M

od

erat

e-vi

go

rou

s P

A (

min

/day

)Q

ual

ity

of

life

(Sco

re)

01.05.2010

9

……whywhy successfulsuccessful

• Change of the social environment

• Inclusion of everybody

• Expert physical education teachers

• „mandatory“ approach

• Playful and fun

Kriemler&Zahner 10 BMJ

Environmental Environmental oror policypolicyapproachesapproaches

• Efforts of worksites, coalitions, agencies,

and communities to createcreate accessaccess toto

placesplaces where people can be active


Environmental Environmental andand policypolicy

ChangeResults of intervention

trials

Community-scale urban design and land use policies

Recommended

↑access to places for PA Recommended

Street-scale urban design/land use policies

Recommended

Transportation and travelpolicies and practices



PuttingPutting all all togethertogether: : EPODEEPODE

• Community-based childhood obesity prevention program in France

• Global effort of the whole community including shop owners, teachers, doctors, pharmacists, caterers, restaurant owners, sport

associations, media, scientists and the town government

www.epode.fr

01.05.2010

10

……whywhy isis thisthis so so geniousgenious

• Global work of the whole community

• everybody takes part

• Costs: 2 Euros per year and inhabitant

……andand itit worksworks !!! !!!

Romon 08 Public Health Nutr

3. 3. KeysKeys ofofan an effectiveeffective Public Public HealthHealth approachapproach

Focus on :Focus on :

•• 11°°prevention

•• childrenchildren where habit change is still doable

• the socialsocial systemsystem and environmental environmental changechange

…. …. PossiblePossible nightmarenightmare

Politicians:

politicans.mpeg

…. …. dreamdream

with know how and a long-term view

Politicians:

…. …. mymy dreamdream

http://youtube.com/watch?v=XQcVllWpwGs

know how

Vision:Politicians:

01.05.2010

11

…. …. mymy dreamdream

http://youtube.com/watch?v=XQcVllWpwGs

know how

Vision:Politicians:

He will never forget….

thanksthanks !!

…. but…. but

1 000

1 500

2 000

2 500

3 000

1960 1965 1970 1975 1980 1985 1990 1995 2000

Cig

are

ttes/

gra

ms

per

adult

First tobacco law

New tobacco law

Tobacco and Health

Reports

Statistics Finland 1998

…. but…. but

1 000

1 500

2 000

2 500

3 000

1960 1965 1970 1975 1980 1985 1990 1995 2000

Cig

are

ttes/

gra

ms

per

adult

First tobacco law

New tobacco law

Tobacco and Health

Reports

Statistics Finland 1998

perhaps a more draconic action is needed….

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