Why Schools Should Promote Physical Activity and Healthy Eating and Prevent Tobacco Use

1. Centers for Disease Control and Prevention Division of Adolescent and School Health Why Schools Should Promote Physical Activity and Healthy Eating and Prevent Tobacco Use Making the Case: Howell Wechsler, Ed.D., MPHHealth Scientist (Part 1)

2. Overview of The Case (1) Promoting physical activity, healthy eating, and tobacco use prevention for youth is a critical public health priority (2) Prevalence of physical inactivity, poor eating behaviors, and tobacco use among youth is high, with unfavorable trends

3. Overview of The Case (3) Promoting physical activity, healthy eating, and tobacco use prevention for youth is an important educational priority • Educational benefits • Benefits for society • Desired by families

4. Regular Physical Activity Reduces Risk Of: premature mortality in general death from heart disease diabetes colon cancer hypertension

5. coronary heart disease stroke type 2 diabetes osteoporosis breast cancer colon cancer prostate cancer Dietary factors are associated with:

6. Cigarette smoking causes: heart disease stroke cancer of the lung, larynx, esophagus, pharynx, mouth, bladder chronic lung disease Cigarette smoking contributes to: cancer of the pancreas, kidney, cervix

7. Causes of All Deaths in the U.S., 1997 Cardiovascular Disease 39% Other Causes 30% Diabetes 3% COPD 5% Cancer 23% Source: CDC, National Vital Statistics Reports 2000: 47(19)

8. 500,000 400,000 400,000 300,000 300,000 200,000 100,000 90,000 100,000 30,000 20,000 0 Tobacco Diet/Activity Alcohol Microbial Sexual Illicit use of agents behavior drugs Actual Causes of Death in the United States, 1990 Source: McGinnis JM, Foege WH. JAMA 1993;270:2207-12.

9. 350 $286 300 250 200 $ in billions 150 $107 $98 100 50 0 CVD1 Cancer2 Diabetes3 Estimated Annual Direct and Indirect Costs of CVD, Cancer, and Diabetes in the U.S. (in $ billions) 1 - Health care and lost productivity costs (American Heart Association); 2 - Health care, lost productivity, and mortality costs (National Cancer Institute); 3 - Medical care costs and lost wages (American Diabetes Association)

10. Estimated Annual Costs Attributable to Obesity and Cigarette Smoking in the U.S. Obesity1 • Direct health care costs: $39 - $52 billion • 4.0% - 5.7% of all health care costs • Indirect costs: $47 billion Cigarette Smoking2 • Direct medical care costs: $53 billion • 6.5% of all health care costs Sources: (1) Wolf AM, Colditz GA. Ob Res 1998;6:97-106; Allison DB et al. AJPH 1999; 88:1194-9 (2) Miller VP et al. Soc Sci Med 1999;48:375-91

11. Consequences of Osteoporosis • Contributes to 90% of hip fractures in women, 80% in men • Virtually all hip fracture patients are hospitalized; 2/3 don’t return to prior level of function • Estimated 1995 health care expenditures for hip fractures: $8.7 billion Source: U.S. DHHS. Healthy People 2010 (Conference Edition), 2000

12. 80% of adult smokers started smoking before they finished high school Source: U.S. DHHS. Surgeon General’s Report: Preventing Tobacco Use Among Young People, 1994 Why Target Youth?

13. Why Target Youth? • The younger people are when they start using tobacco, the more likely they are to become dependent on nicotine • 25% of high school students smoked a whole cigarette before age 13* • Physical activity and dietary patterns may be established during childhood and adolescence *CDC, National Youth Risk Behavior Survey, 1997

14. Why Target Youth? • Risk factors for heart disease and diabetes develop early in life Triglycerides LDC-Cholesterol HDL-Cholesterol (low) Insulin Blood Pressure

15. Why Target Youth? • Risk factor trends are going in the wrong direction • Atherosclerosis is present in late adolescence

16. Why Target Youth? • % of children, aged 5-10, with 2 or more adverse CVD risk factor levels: • % of children, aged 5-10, with 1 or more adverse CVD risk factor levels: 27.1% 6.9% Source: Freedman DS et al. Pediatrics 1999;103:1175-82

17. Study Years (n) Ages Significant Site Increases In: 1981 (417) Weight, body 1 Louisiana 16-17 1991 (235) mass, triglycerides Weight, body 1973-5 (299) mass, total choles- 2 Ohio 7-13 1989-90 (1456) terol, triglycerides, blood pressure Weight, body 1986 (4239) 3 Minnesota 10-14 mass, systolic 1996 (5223) blood pressure Trends in Coronary Risk Factors in Children Sources: (1) Gidding SS et al. J Pediatr 1995;127:868-74 (2) Morrison JA et al. Am J Public Health 1999;89:1708-14 (3) Luepker RV et al. J Pediatr 1999;134:668-74

18. overweight overweight Why Target Youth? • % of children, aged 5-10, with 1 or more adverse CVD risk factor levels: • % of children, aged 5-10, with 2 or more adverse CVD risk factor levels: 27.1% 60.6% 6.9% 26.5% Source: Freedman DS et al. Pediatrics 1999;103:1175-82

19. Relation of Overweight to Adverse CVD Risk Factors in Children Ages 5-17 FactorOdds Ratio* Cholesterol >200 mg/dl 2.4 Triglycerides >130 mg/dl 7.1 LDL-C >130 mg/dl 3.0 HDL-C < 35 mg/dl 3.4 Elevated SBP 4.5 Elevated DBP 2.4 Elevated insulin 12.6 *Prevalence for overweight children (> 95th percentile for Quetelet Index) versus prevalence for children who are not overweight or at risk of overweight (< 85th percentile) Source: Freedman DS et al. Pediatrics 1999;103:1175-82

20. Percent 11.4 12 10 9.9 8 6 4 2 0 1963-70 1971-74 1976-80 1988-94 Percentage of U.S. Adolescents, Ages 12-17, Who Were Overweight*, by Sex Females 4.5 Males 4.6 * >95th percentile for BMI by age and sex based on NHANES I reference data Source: Troiano RP, Flegal KM. Pediatrics 1998;101:497-504

21. Percent 11.4 12 9.9 10 8 6 4 2 0 1963-70 1971-74 1976-80 1988-94 Percentage of U.S. Children, Ages 6-11, Who Were Overweight*, by Sex Males 4.3 Females 3.9 * >95th percentile for BMI by age and sex based on NHANES I reference data Source: Troiano RP, Flegal KM. Pediatrics 1998;101:497-504

22. Percent Black females 18 16 14 12 10 8 White females 6 4 2 0 1963-70 1971-74 1976-80 1988-94 Percentage of U.S. Children, Age 6 to 11,Who Were Overweight*, by Race and Sex Black males White males * >95th percentile for BMI by age and sex based on NHANES I reference data Source: Troiano RP, Flegal KM. Pediatrics 1998;101:497-504

23. Emergence of Type 2 Diabetes Among Youth • 1979: First clinical reports in Pima Indians in Arizona • 1990-94: First clinical reports in populations other than American Indians

24. Increased Incidence (New Cases) of Type 2 Diabetes Among Adolescents in Greater Cincinnati, OH • Incidence in 1982: 0.7 / 100,000 per year • Incidence in 1994: 7.2 / 100,000 per year Source: Pinhas-Hamiel O et al. J Pediatr 1996;128:608-15

25. Type 2 Diabetes in Youth • A public health problem for American Indians (estimated prevalence: 2 to 50 per 1000) • Becoming a public health problem for popula-tions other than American Indians (estimated prevalence: <4 per 1000 in general population) • approximately 30,000 adolescents aged 12-19 in 1988-94 • 8 to 46% of all new cases of diabetes in pediatric clinics Source: CDC, Division of Diabetes Translation

26. Hyperlipidemia Diabetes mellitus Hypertension Respiratory Cardiac Polycystic ovary disease Gall bladder disease Osteoarthritis Cancer Health Conditions Associated with Adult Obesity

39. No Data <10% 10%–14% 15%–19% ≥20 Obesity Trends* Among U.S. AdultsBRFSS, 1997 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

40. No Data <10% 10%–14% 15%–19% ≥20 Obesity Trends* Among U.S. AdultsBRFSS, 1998 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

41. No Data <10% 10%–14% 15%–19% ≥20 Obesity Trends* Among U.S. AdultsBRFSS, 1999 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

42. No Data <10% 10%–14% 15%–19% ≥20 Obesity Trends* Among U.S. AdultsBRFSS, 2000 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

43. Obesity Trends* Among U.S. AdultsBRFSS, 2001 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

44. Obesity Trends* Among U.S. AdultsBRFSS, 2002 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% Source: Behavioral Risk Factor Surveillance System, CDC

45. Healthy People 2010: Leading Health Indicators • Substance abuse • Responsible sexual behavior • Mental health • Injury and violence • Environmental quality • Immunization • Physical activity • Overweight and obesity • Tobacco use • Access to health care

46. Objectives to be Measured to Assess Progress in Leading Health Indicators • Increase the proportion of adolescents who engage in vigorous physical activity that promotes cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion. • Reduce the proportion of children and adolescents who are overweight or obese. • Reduce cigarette smoking by adolescents.

47. Sound Bytes “No [health] problem needs our attention more than the growing epidemic of obesity in America. In sheer numbers and its toll in death and disability, obesity has reached crisis proportions in the United States.” - Dr. C. Everett Koop, former United States Surgeon General

48. Sound Bytes “Smoking is the chief, single avoidable cause of death in our society and the most important public health issue of our time.” - Dr. C. Everett Koop, former United States Surgeon General

49. Sound Bytes “I am alarmed by the steady trend we have seen over the last two decades toward decreasing physical education requirements in schools... We need to create environments where healthy lifestyles are as easy to adopt as unhealthy ones…Our schools have a responsibility to educate both minds and bodies.” - Dr. David Satcher, U.S. Surgeon General

50. Sound Bytes “Smoking kills more people than AIDS, alcohol, drug abuse, car crashes, murder, suicides, and fires combined.” - Centers for Disease Control and Prevention, Office on Smoking and Health