Despite our best efforts, pediatricians have little success in encouraging our patients to eat a healthy diet and get the recommended amount of daily physical exercise.
Despite our best efforts, pediatricians have little success in encouraging our patients to eat a healthy diet and get the recommended amount of daily physical exercise. According to 2012 data, over 31% of US children aged 2 to 19 years are either obese or overweight, and over 80% of teenagers do not get the recommended amount of physical activity.1,2
Activity meters may hold the key to encouraging our young patients to increase their levels of moderate to vigorous daily exercise. Kids are quite tech savvy these days, and love their video games, smartphones, and computers. By leveraging technology, pediatricians may be able to improve children’s activity levels and begin to achieve reductions in childhood obesity levels.
Today, too many children are inactive! Inactivity has been shown to be an independent risk factor for the development of cardiovascular disease, type 2 diabetes, hypertension, and colon cancer.5 Inactivity in turn is associated with obesity that can lead to type 2 diabetes, hypertension, hyperlipidemia, stroke, heart disease, and nonalcoholic fatty liver disease, as well as arthritis, sleep apnea, asthma, poor self-esteem, and depression.4
The US Department of Health and Human Services recommends that children and adolescents aged 6 to 17 years participate in at least 60 minutes of physical activity daily.5 Yet, in 2013, only 27.1% of high school students surveyed had participated in at least 60 minutes per day of physical activity on all 7 days before the survey, and only 29% attended physical education class daily.6
I can tell you from my personal experience that pediatricians spend a lot of time at well visits encouraging overweight patients to eat a healthy diet and exercise daily, but only a small number of patients follow these recommendations. On the other hand, there is data that tertiary “obesity” care clinics, which have the resources to provide overweight children with the services of endocrinologists, nutritionists, gastroenterologists, psychologists, and other specialists, can produce sustainable weight loss in obese pediatric patients.7 We clinic-based pediatricians, however, with our limited resources need a more effective way to combat childhood obesity and inactivity. What we are doing is just not enough.
Pierre Omidyar became wealthy after his company eBay went public in September 1998. His wife Pam Omidyar put their fortune to good use by starting the nonprofit HopeLab Foundation (Redwood City, California) in 2001. The mission of the HopeLab Foundation is to research and develop products that harness technology to improve health and well-being. In 2006, HopeLab released a video game called Re-Mission for children with cancer, to help young patients better cope with their illness. The game was studied at over 34 cancer centers involving over 300 pediatric patients. Its use was associated with higher blood levels of chemotherapeutic agents and improved compliance with prescribed antibiotics, as well as other measures.8
Several years ago in 2011, HopeLab developed Zamzee, an activity meter designed to help physicians motivate children and adolescents to get more daily exercise. The original Zamzee device (Figure 1) was a USB-based "3D accelerometer" that integrated with an interactive motivational website (www.zamzee.com; Figure 1).
Zamzee.com is an online playground where participants are rewarded for daily exercise and goal achievement. Children log on to the website to compete with friends, accumulate virtual dollars, and purchase virtual prizes or real prizes (gadgets, stickers, gift cards, and more), or they can donate their rewards to charity. Keeping with its mission to research promising technology, HopeLab partnered with the Robert Woods Johnson Foundation to study how effective Zamzee could be for increasing activity among middle-school children.
In the study of 448 overweight and obese children, the intervention group used the device in conjunction with the Zamzee motivational website and was compared with those using the Zamzee only. As shown in Figure 2, those children in the intervention group had significantly more activity than those who used the activity meter only. The study demonstrated improvement in lipid studies and hemoglobin A1C levels among patients in the Intervention group. Surprisingly, the intervention group did not demonstrate a significant change in body mass index (BMI).
For several years, HopeLab sold the Zamzee activity meter at $30 each and eventually distributed about 10,000 of the devices. In 2014, HopeLab decided to redesign its device and program. The meter was upgraded from a device that plugged directly into a USB port to one that connects via a USB cable to a computer to access the website. The upgraded activity meter (Figure 3) also can access a mobile Zamzee app on tablets or smartphones via Bluetooth connectivity.
HopeLab unfortunately no longer sells its activity meter and is now seeking alliances with strategic partners (large clinics, obesity clinics, and schools) to research how best to use the device in ways that will have the most positive impact on childhood obesity and inactivity. The company’s goal is to accumulate data that will compel "stakeholders" such as insurance companies and the government to provide the Zamzee devices, free of charge, as part of a comprehensive program to improve the health of our children.
America on the Move (AOM) is a nonprofit organization that encourages Americans to make small lifestyle changes that can stabilize or reduce weight among overweight adults and children. The AOM initiative recommends that adults and children reduce their calorie consumption by 100 kcal per day (which can be achieved simply substituting sucralose for sugar in the diet) and increase physical activity by walking an additional 2000 steps per day (over baseline).
A study was performed over 10 years ago to measure the effects of these small changes on the health of overweight pediatric patients. One hundred forty-nine overweight pediatric patients following the above guidelines for 6 months were compared with a matched control group. Sixty-seven percent of the intervention group maintained or reduced BMI for age compared with 53% in the nonintervention group, whereas only 33% of the intervention group increased their BMI above baseline, compared with 47% in the nonintervention group.9
The takeaway from this study is that if pediatricians can achieve small changes in the diet and activity level of committed and motivated patients, we can begin to improve the health of our patients.
Until such time that HopeLab completes its research with its redesigned activity meter and again makes the device available, we will need to make due with alternative technologies. Fortunately several alternatives are available.
GeoPalz LLC (Boulder, Colorado) produces inexpensive GeoPalz pedometers for kids that come in a variety of kid-friendly designs. The company also has an interactive website that can help motivate kids to keep moving. Kids register for the website and record their daily steps. When kids achieve goals, they can receive free rewards (eg, flying discs, balls, yo-yos). Family members also can enroll in the program to help motivate their offspring, and alternative pedometers can be used. GeoPalz will e-mail monthly reports to patients so they can keep track of their progress.
GeoPalz has also released a Bluetooth pedometer for kids and family, called ibitz that communicates wirelessly with several motivational applications on smart devices. Other ibitz-related rewards for kids include unlocking special features in popular video games such as Minecraft.
Smart devices can be most helpful in that they can help our patients keep track of calories consumed each day. By counting calories in order to meet daily goals, our patients are motivated to make better food choices. Examples of good calorie-counter apps include MyFitnessPal from MyFitnessPal Inc and Fooducate from Fooducate Ltd.
Most of our patients spend too much time in front of video consoles, getting little exercise except for moving fingers used to operate game controllers. We should keep in mind that there are several video games and consoles that can be used to get kids moving.
The Wii video game system from Nintendo Co Ltd (Kyoto, Japan), for example, has handheld video game controllers that can be used with Wii Sports to play virtual games of tennis and bowling among others. Kids can get aerobic exercise and burn calories this way, even in winter. The Xbox system (Microsoft; Redmond, Washington) has a motion-sensing technology via its Kinect controller that can be used with select video games in a similar fashion. Popular exercise games for video systems include Kinect Sports, DanceDance Revolution, EA Sports Active 2, and Just Dance 2015.
As stated at the beginning of this article, pediatricians typically meet with little success in helping overweight patients become more active and reduce their caloric intake. I am now changing my tactics, based on what I have discovered in researching this article.
One must begin with a motivated overweight child as well as a supportive family. Until the Zamzee activity meter again becomes available I will recommend that my patients visit a nutritionist, obtain a calorie-counting application, and get a pedometer such as the GeoPalz discussed earlier. I will advise patients to enroll in the GeoPalz website and perform a baseline step counting and calorie counting for 2 weeks. Per the AOM study, I will recommend that children increase their daily step counts by 2000 steps per day and reduce their caloric consumption by 100 kcal per day. Children will be seen monthly so I can review their step counts and caloric intake and monitor their weight and BMI.
I would not be surprised if these small steps result in a sustained weight loss and improved activity levels in my patients. In a future article, I'll let you know if this proves to be an effective strategy. Stayed tuned!
1. Ogden CL, Carroll MD, Kit BK, Fiegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814.
2. Hallal PC, Andersen LB, Bull FC, et al; Lancet Physical Activity Series Working Group. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet. 2012; 380(9838):247-257.
3. Strong WB, Malina RM, Blimkie CJ, et al. Evidence based physical activity for school-age youth. J Pediatr. 2005;146(6):732-737.
4. Wang Y, Wu Y, Wilson RF, et al. Childhood Obesity Prevention Programs: Comparative Effectiveness Review and Meta-Analysis. Comparative Effectiveness Review No. 115. AHRQ Publication No. 13-EHC081-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2013. Available at: http://www.ncbi.nlm.nih.gov/books/NBK148737/. Accessed March 5, 2015.
5. Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: US Department of Health and Human Services, 2008. Available at: http://www.health.gov/paguidelines/pdf/paguide.pdf. Accessed March 5, 2015.
6. Kann L, Kinchen S, Shanklin SL, et al; Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance-United States, 2013. MMWR Surveill Summ. 2014;63(suppl 4):1-168.
7. Madsen KA, Garber AK, Mietus-Snyder ML, et al. A clinic-based lifestyle intervention for pediatric obesity: efficacy and behavioral and biochemical predictors of response. J Pediatr Endocrinol Metab. 2009;22(9):805-814.
8. Kato PM, Cole SW, Bradlyn AS, Pollock BH. A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial. Pediatrics. 2008;122(2):e305-e317.
9. Rodearmel SJ, Wyatt HR, Stroebele N. Smith SM, Ogden LG, Hill JO. Small changes in dietary sugar and physical activity as an approach to preventing excessive weight gain: the America on the Move family study. Pediatrics. 2007;120(4):e869-e879.
Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.