Fighting

childhood
obesity
in Northern
California

www.childrenshospitaloakland.org
www.chori.org
www.pediheartcho.org
2 • C HILD REN ’ S HOSPITAL & R E SE ARCH CE NT E R OA K L A N D

About us
Children’s Hospital &
Research Center Oakland
Northern California’s regional pediatric medical center

Children’s Hospital & Research Center Oakland has been committed to improving the health of children in
Oakland and Northern California for almost 100 years. This is why it creates and supports many clinical,
research and educational programs aimed at ending the childhood obesity epidemic.

While Children’s is a 190-bed, nationally recognized pediatric tertiary care

center and research institute, the medical center is also the region’s safety
net, serving counties that have few or no inpatient pediatric beds. In 2009,
Children’s had 10,872 inpatients admissions and 235,352 outpatient visits.

For children in Alameda and Contra Costa counties, where there are no
pediatric beds in public hospitals, Children’s is the de facto safety net
hospital; in fact, a total of 8 counties in the immediate neighboring 14
counties do not have pediatric beds in their public hospitals. More than
70 percent of our patients receive government-funded insurance through
Medi-Cal, and we care for all children regardless of insurance status.
OAKLAND �

23

53
 w w w. c h i l d re n s h o s p i t aloa kla nd.or g • 3

Applicants for Children’s Specialty

Pediatric Residency program: 571 Care
(for 26 first-year positions) Centers: 5
With locations in
Subspecialty fellows: 22 Brentwood, Larkspur,
Modesto, Pleasanton,
Pediatric residents: 78 Walnut Creek
Visiting medical students
from all over the country: 70
Visiting residents in School-
orthopedics, general surgery, based
Founded: 1912 anesthesia, emergency
Health
medicine, family practice: 120
Centers: 2

Specialties: 30
Licensed beds: 190
In addition to being a tertiary
care center for the regions sickest
kids, Children’s is also the major
Basic and clinical
primary care provider for an
research staff: 300
increasing number of children National rank in NIH
health research awards
living nearby. Thirty subspecialty to children’s hospitals: 6
Hospital-based and
community-based
physicians on
Medical Staff: 654
Registered nurses, full-time
and part-time: 762
Employees, full-time and
part-time: about 2,700
Emergency and urgent care
visits: 55,498
NICU admissions: 416
Inpatient admissions: 10,872
Outpatient visits: 235,352
Number of Children’s Hospital
Branches: 14
(Volunteer community-based fundraising groups)

services, representing all the In-hospital volunteers: 900

major pediatric medical and

surgical subspecialties, are available at Children’s. In addition to having the only 100-percent
pediatric emergency room and Level 1 pediatric trauma center in Northern California, the medical
center has:

• 44-bed Neonatal Intensive Care unit

• 23-bed Critical Care unit
• 18-bed Pediatric Rehabilitation unit
• 26-bed Hematology/Oncology unit including a 12-bed immuno-compromised unit for Blood
and Marrow Transplantation and Oncology patients.

Located in one of the most diverse communities in California and the United States, Children’s
Hospital Oakland has many community partnerships and programs including two cutting-edge,
school-based clinics, where high-risk youth receive health and mental health services from
Children’s physicians and psychologists. Children’s is also the healthcare provider for the county
juvenile facility offering full medical care to incarcerated youth.

Children’s has the largest sickle cell program in the Western United States, and serves children and
adult patients. In addition to treating those with sickle cell disease, the program researches cures
and treatments for the disease and its complications, offering the best opportunities for survival and
preservation of the quality of life.
4 • C HILD REN ’ S HOSPITAL & R E SE ARCH CE NT E R OA K L A N D

Federal Congressional Districts

served by Children’s Hospital & Research Center Oakland
Federal
January Congressional
1, 2009 Districts
served by
– December 31, 2009
Children’s Hospital & Research Center Oakland
January 1, 2009 – December 31, 2009

Over 10,000 patient visits

1,000 - 9,999 patient visits
2
4 1-999 patient visits

1
Children’s Payer Mix Trend
5 2006 2007 2008 2009 2009-Dec
6 3
7 10
Govt/Medi-Cal 61.6% 59.8% 60% 64.8% 71.3%
� 10 Commercial 38.4% 40.2% 40% 35.2% 28.7%
8 9 19
12 11
13
16
14 15 18

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53

Northern California Children’s Patient Ethnic Breakdown

Ethnicity 2008 2008

In Northern California,
63% of children are classified Outpatient Inpatient
as ethnic minorities.

Black - 5% Black - 28% Black - 20%

Latino - 26% Latino - 34%
Latino - 40%
Other - 17% Other - 18%
Other - 6% Causasian - 15% Causasian - 20%
Caucasian - 37% Unknown - 8% Unknown - 1%
Asian - 12% Asian - 6% Asian - 7%
N=2.3M
 w w w. c h i l d re n s h o s p i t aloa kla nd.or g • 5

Fighting childhood obesity

in Northern California

Children’s Hospital & Research Center Oakland is on the front lines of the
nation’s childhood obesity epidemic. Over the past decade, our endocrinologists
have been sounding alarms about the rising rate of diabetes in our pediatric
population, and our cardiologists have been treating children with previously
adult-only cardiovascular conditions caused by obesity and diabetes. About 34
percent of the children who walk in our doors are overweight or obese.

With a depth of clinical and basic research and public health experience,
Children’s is uniquely qualified to attack this raging public health fire. Our
clinicians and scientists established one of the first clinics devoted to pediatric
weight management in the region. The program, Healthy Eating Active Living
(HEAL), evolved into the Healthy Hearts program championed by our Cardiology
department. This multidisciplinary program incorporates exercise, nutrition
education, and counseling.

Meanwhile, at our research institute, scientists such as Bruce Ames, PhD; Ronald
Krauss, MD; Janet King, PhD; and Michele Mietus-Snyder, MD, all nationally
recognized leaders in nutrition and cardiovascular disease research, are seeking
solutions to the national overweight and obesity problem.

Children’s Hospital also stresses community-based projects—exercise programs

for kids, healthy snacks on wheels and more—as well as education to better
prepare our pediatric residents to prevent and manage obesity.
6 • C HILD REN ’ S HOSPITAL & R E SE ARCH CE NT E R OA K L A N D

Clinical Children’s Hospital’s clinicians were early responders

to the epidemic of childhood obesity. In 2003, a team
of physicians, nutritionists, psychologists and exercise
physiologists established the Healthy Eating, Active Living
(HEAL) Clinic. While HEAL was clinically successful, it was
challenged by poor reimbursement from health insurance
companies.

In 2008, the Pediatric Cardiology Medical Group-East Bay

Inc., the Cardiology practice at Children’s Hospital Oakland,
re-opened and re-launched HEAL under the name Healthy
Hearts. Healthy Hearts’ clinical approach is multidisciplinary
and comprehensive. The program offers culturally sensitive,
individualized family support, comprehensive care, and
provides resources for community programs designed to
encourage healthy lifestyle changes.
 w w w. c h i l d re n s h o s p i t aloa kla nd.or g • 7

Fighting childhood obesity one

child at a time
Healthy Hearts offers a multidisciplinary approach to
managing weight and supporting a healthier lifestyle for
the whole family

A
t a 2003 town hall meeting in
Oakland, local parents were
alarmed and wanted to know
how to help their overweight kids, many
of whom had diabetes. In response,
a group of doctors and scientists at
Children’s Hospital & Research Center
Oakland opened the Healthy Eating
Active Living (HEAL) clinic as an obesity
prevention and treatment program.
In addition to treating obesity and
comorbidities, HEAL emphasized lifestyle
changes including improved diet and
increased exercise as ways to deal with
obesity. HEAL clinicians recognized that
families as a whole needed help with food
and activity choices and recommended
ways families could live healthier lives.
In the four years following the clinic’s
opening, HEAL served more than 475
kids who were overweight or at risk of
becoming overweight.
In July 2008, HEAL closed due to a
lack of funding. The Pediatric Cardiology
Medical Group–East Bay, Inc., the
Cardiology practice at Children’s Hospital
Oakland, soon reopened and reinvented
the program under a new name: Healthy
Hearts.
Healthy Hearts is a multidisciplinary
program designed to prevent and treat
childhood obesity and related illnesses.
The program offers culturally sensitive,
individualized family support and provides
resources for community programs
designed to encourage healthy lifestyle
changes. It is open to youth between
the ages of 2 and 18 who are obese
or overweight, or normal weight with
demonstrated family risk factors for
high blood cholesterol and triglycerides,
hypertension or diabetes.
Working with patients and families,
the program sets goals and tailors clinic
visits and education materials to each
patient’s individual needs and readiness
to change their lifestyle. The program
involves hands-on teaching about SacramentoSacramento
Solano County
County
Napa

Percentage of overweight or obese children, 2007-08 San Joaquin

County

Marin
County Stockton
Contra Costa
County
Oakland
San Francisco

Alameda
County

San Jose
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53

National Averages State of California Oakland School District

Overweight children – 32% Grade 5 – 32% Grade 5 – 36%
(Ages 2 to 19) Grade 7 – 32% Grade 7 – 39%
Obese children – 16% Grade 9 – 30% Grade 9 – 39%
(Ages 2 to 19)
8 • C HILD REN ’ S HOSPITAL & R E SE ARCH CE NT E R OA K L A N D

Clinical
nutrition and exercise for patients and
their families.
Healthy Hearts takes a holistic
approach to kids’ health, and our
clinic includes a registered dietitian, an
exercise physiologist, a psychologist and
cardiologists.
During each clinic visit, the child and
family meet a physician and one of the
team specialists.
Patients receive care and counseling
over the course of six visits, about four
weeks apart, with follow-up visits three
and six months after completion of the
program. Each visit lasts one hour.
In addition to working with patients
and families on behavioral management,
Healthy Hearts manages many of our
patient’s associated comorbidities such as
high blood cholesterol and triglycerides.
The program works closely with other
Children’s Hospital departments to
coordinate subspecialty care for kids with
obesity-related health problems.
Healthy Hearts uses an electronic
medical record system that helps us
refine our interventions and develop best
practices.
Healthy Hearts follows the expert
guidelines established by the Centers
for Disease Control and Prevention,
the Health Resources and Services
Administration and the American Medical
Association. The program uses evidence-
based solutions to treat obesity, including:
• Eating breakfast every day
• Eating at least five servings of fruits
and vegetables per day
• Having regular family meals
• Limiting sugar-sweetened beverages
• Limiting portion sizes
• Limiting eating out, especially at fast
food restaurants
• Doing moderate to vigorous physical
activity for at least 60 minutes per day
• Removing television from children’s
bedrooms
• Limiting screen time (TV, computer,
and video games) to two hours or less
per day
The Pediatric Cardiology Medical
Group–East Bay, Inc. is the primary
funder of Healthy Hearts, and since
founding the program in 2008, it has
significantly increased the program’s
patient capacity and services offered at
Children’s Hospital Oakland and affiliated
outreach clinics. In 2009, Healthy Hearts
provided services to 482 patients.

Healthy Hearts patient population

Patients seen per site BMI Severity of disease Fairfield

Oakland - 55% Obese - 92% Pre-diabetic - 11%
Walnut Creek - 26% Morbidly obese - 66% High LDL-cholesterol - 36% Walnut
Fairfield - 10% Larkspur Creek
High triglycerides - 46%
Oakland
Larkspur - 9% Ages
Under 8 years - 18%
Patients served* 8 to 12 years - 45% Household incomes
586 patients 13 and older - 37% 0 and $15,000 - 25%
1507 patient visits total $15,000 and $30,000 - 24%
Gender $30,000 and $45,000 - 12% Four
Ethnicity Male - 54% ≥$45,000 - 39%
clinic sites:
African American - 18% Female - 46% • Fairfield
Latino - 53% • Larkspur
White - 25% • Oakland
Asian - 8% * Prior to Healthy Hearts, HEAL • Walnut Creek
served more than 475 patients
 w w w. c h i l d re n s h o s p i t aloa kla nd.or g • 9

Healthy Hearts Program

OBJECTIVE:
To prevent and treat childhood obesity and related illnesses, such as diabetes,
heart disease and high blood pressure. Healthy Hearts staff offers culturally
sensitive, individualized family support and access to community programs
designed to encourage healthy lifestyle changes.
THE PROGRAM:
Visit 1: Initial Evaluation and Assessment - A healthcare professional builds a relationship with the
patient and family. The visit includes a thorough physical exam and establishes program goals.
Visit 2: Nutrition - A registered dietitian discusses healthy eating choices, including current food options
and offers an individualized nutrition plan.
Visit 3: Physical Activity - An exercise specialist discusses active living habits and offers exercise
prescriptions.
Visit 4: Feelings and Families - A mental health specialist discusses body image and self-esteem, as well as
parenting, family dynamics and cultural issues.
Visit 5: Healthy Lifestyle - Families discuss with the dietitian or exercise specialist their progress in self-
managing their goals or how to modify them as needed.
Visit 6: Summary Visit - The team and family assess accomplishments and progress toward goals, and
develop a plan for sustaining healthy eating and active living habits.
Visits 7 and 8: Follow up - Three and six months to assess healthy lifestyle changes.

FUNDING SOURCE FOR HEALthy HEARTS Prescription

HEALTHY HEARTS: Name__________________________________________ Date: ________________

Pediatric Cardiology Medical Group-East Bay, Inc.

Aetna Foundation Nutrition Evidenced-Based Recommendations:
Irwin Home Equity (IHE) Foundation Individual Goals What Works!
No sugar-sweetened beverages

Safeway Foundation Breakfast everyday

Limit eating out (fast food)

FUNDING SOURCE FOR HEAL: Limit portion sizes

Eat at least 5 servings of fruit and vegetables

Children’s Hospital & Research Center Oakland Have regular family meals

Alameda County Public Health Department Physical Activities: Evidence-based Recommendations:

Individual Goals What works!
Morris Stulsaft Foundation Limit screen time to no more than 2 hours a
day

Fidelity Foundation Remove the TV from child’s bedroom

Moderate to vigorous physical activity for at

Irwin Home Equity (IHE) Foundation least 60 minutes a day

San Francisco Foundation

YES I CAN !
Signature____________________________________

Every Healthy Hearts patient receives recommendations for healthy

eating and exercise tailored to their specific needs.
10 • C HI LD REN’ S HOS PITAL & R E SE ARCH CE NT E R OA K L A N D

Education Children’s Hospital & Research Center Oakland is a

nationally recognized teaching hospital. In addition to
training pediatric residents, subspecialty fellows and
medical students, the hospital has a program introducing
underrepresented minority high school students to the
healthcare professions called FACES for the Future (FACES)
and a summer research internship for high school students
and college undergraduates.

Currently, our residents are participating in a statewide

pilot program called Fit for Residency. Led by the University
of California, Los Angeles, this program is developing
curriculum and training pediatric residents to effectively
council their future patients and patient families about
healthy living and weight management. Many FACES interns
teach critical health and nutrition information at Oakland
and Berkeley elementary schools to encourage kids to live
healthy lives.
 w w w. c h i l d re n s h o s p i t al oa kla nd.or g • 11

FACES for the Future Youth Health Educators

FACES for the Future Health Scholars Academy (FACES) at Children’s Hospital &
Research Center Oakland is a three-year education program for high school students
focused on increasing diversity in the healthcare and biomedical professions and
improving the quality of healthcare in underserved communities.

OBJECTIVE:
FACES Youth Health Educators teach critical health and nutrition information at
Oakland and Berkeley elementary schools to encourage kids to live healthy lives.

THE PROGRAM:
The Youth Health Educators curriculum includes units on nutrition and health issues, such as obesity,
diabetes, heart disease and asthma. By teaching grade school kids about the importance of nutrition and
their health, FACES health educators strive to minimize the probability that the kids will develop these
conditions or suffer the worst consequences of them.

4th Grade Unit: Nutrition: Balance & Imbalance

The nutrition lessons for 4th graders focus on energy and nutrient balances and imbalances. The lessons
reinforce healthy eating habits and warn against the health risks caused by excessive weight gain. The
students learn about:
• Calories • Healthy foods • Carbohydrates • The benefits of exercise
• Energy • Protein • Vitamins
• Food labels • Fat • Minerals

5th Grade Unit: Nutrition & Diabetes

The nutrition and diabetes lessons cover basic nutrition, the anatomy of the digestive system and diabetes
diagnosis, prevention and treatment.
Outreach
• This spring FACES health educators will visit classrooms in Berkeley and Oakland to teach about 350 4th
and 5th graders
• In March 2010, FACES health educators taught at Roosevelt Middle School’s Health Fair attended by 400
children
• In May 2010, 15 health educators will host a Family Science Festival for the Oakland and Berkeley public
schools and high-school teachers. This event targets K-5 students and their families and introduces them
to health issues in a venue where they can have fun learning together. The festival’s inter-active learning
stations cover topics including healthy serving sizes, nutrition and energy balance, and the amounts of
sugar and fiber in different cereals and sodas.

FUNDING SOURCE:
The SEEK (Science Exploration, Excitement, and Knowledge) Curriculum used by FACES health
educators was developed by Children’s Hospital Oakland Research Institute and the Hall of Health under
a Science Education Partnership Award (SEPA) from the National Institutes of Health (NIH). Children’s
received $1.3 million in grants from the NIH to develop and test the curriculum, and now to publish it as a
book.
12 • C HI LD REN’ S HOS PITAL & R E SE ARCH CE NT E R OA K L A N D

Education
Teaching Future Physicians to Prevent and Manage Obesity:
Residency Training at Children’s Oakland

Because pediatric residents currently receive minimal training in prevention

and management of overweight and obesity, many primary care pediatricians
are unprepared to effectively deal with these health problems. To improve
residency training in California and across the United States, Children’s Oakland
is participating in a statewide pilot program, Fit for Residency, led by UCLA. Lydia
Tinajero-Deck, MD, co-director of Healthy Hearts, leads these efforts at Children’s.

OBJECTIVE:
Fit for Residency’s goal is to reduce rates of pediatric obesity, type 2 diabetes and
heart disease through improved pediatric residency training.
THE PROGRAM:
Pediatric residents learn about physical activity, nutrition, and diagnoses and managment of obesity, so they
can effectively council future patients and patient families about healthy living and weight management.
Fit for Residency at Children’s Oakland teaches residents to:
• Make sure patients are eating breakfast
• Assess whether water and milk intake is adequate
• Assess how much sugary beverage is consumed
• Check the daily number of servings of fruits and vegetables
• Assess how often patients eat out and consume high calorie snacks
• Assess kids physical activity and encourage 60 minutes of moderate to vigorous activity per day
• Measure BMI and assigning whether patients are healthy weight, overweight or obese.
For kids who are overweight or obese, residents learn to:
• Assess children’s overall mental health including depression and low self-esteem
• Learn how to teach kids about nutrition and exercise during office visits
• Learn why overweight and obese kids need to have follow-ups every three months
• Diagnose comorbidities such as hypertension, high cholesterol, type 2 diabetes and obstructive lung
disease
• Learn to refer kids to subspecialists for comorbidities.
Fit for Residency will collaborate with similar residency programs in California and across the United States
to share curriculum innovations with residency program faculties.
 w w w. c h i l d re n s h o s p i t al oa kla nd.or g • 13

CHORI Summer Research Program

Undergraduate, medical and graduate students converge every year at Children’s
Hospital Oakland Research Institute (CHORI) for its eight-week CHORI Summer
Research Program. Each student takes on a research project, establishes hypotheses,
writes protocols and methodologies, requests approval from the Institutional Review
Board, reaches conclusions and presents findings to their peers.

OBJECTIVE:
To provide summer research opportunities for undergraduate students, medical
students, and students studying to be healthcare professionals.
2009 STUDENT PROJECT HIGHLIGHTS:
Graciela Espinoza
Cal Poly State University, San Luis Obispo
Mentor: Jodi Stookey, PhD
“Rates of Fat Oxidation After Drinking
Orange Juice Versus Water with Breakfast”
Objective: To describe and compare change
in the rates of fat oxidation over three-hours
after breakfast paired with water versus orange
juice. The testing done in this study will also
benefit the participants by showing them how
their body reacts and metabolizes a typical
breakfast meal.
Wendy Joselyn Gordillo
San Francisco State University
Mentor: Patricia Wakimoto, PhD
“Latinos’ Perspectives on Research”
Objective: 1.) To examine concerns and issues
surrounding medical and genetic research in
the Latino population 2.) To develop effective
strategies to address some of the barriers
faced by researchers working with the Latino
community.
Mike Huynh
California State University, East Bay
Mentor: Tariq Ahmad, MD
“Barriers to Glycemic Control Amongst
Diabetic Patients of the Bay Area”
Objective: To investigate whether factors
such as the patients’ usage of government
assistance, city of residence, household
income, duration of time required to travel
to clinic, primary language, ethnicity,
and insurance provider affect the HbA1C
percentile, ∆HbA1C , blood pressure, body
mass index percentile, deviation of growth
(CDC growth charts), and are thus associated
with the inequalities of glycemic control
amongst diabetic patients of the Bay Area.
Daisy Mendoza
California State University, East Bay
Mentor: Janelle Noble, PhD
“Association of HLA Loci in African-
Americans and Hispanics with Type 1
Diabetes Mellitus”
Objective: The purpose of this study was
to analyze genetic associations of alleles in
African-American T1D patients from CHO.
Later, the study was expanded to include all
ethnicities, multiple genes, and patients from
other institutions. Currently there are a total
of 357 T1D patients and family members
enrolled.
Kayvahn Pierce Steck-Bayat
University of Washington, Seattle
Mentor: Bruce Ames, PhD
“The Impact of Intensive Lifestyle
Counseling on the Poor Nutritional State
of Obese Inner City Children”
Objective: To evaluate the nutritional status
of inner city obese children, and the impact
of intensive lifestyle counseling, that includes
healthy dietary guidance.

FUNDING SOURCE:
In 2009, CHORI received a $1 million award from the NIH to support the summer research program
for the next five years. The award provides stipends for 18 undergraduate students from socioeconimically
challenged backgrounds, as well as for two medical students. The program also provides opportunities for
high school and undergraduate volunteer students.
14 • C HI LD REN’ S HOS PITAL & R E SE ARCH CE NT E R OA K L A N D

Research Basic research performed at Children’s Hospital Oakland

Research Institute (CHORI)—the research arm of Children’s
Hospital Oakland—is a crucial part of the hospital’s fight
against obesity.

CHORI is the home of the Center of Excellence for

Prevention of Obesity, Diabetes and Cardiovascular Disease.
Principal investigators in the Center’s research collaboration
include Ronald Krauss, MD—who leads the Cardiovascular
Lipid Laboratory—as well as Bruce Ames, PhD, and Janet
King, PhD, of the Nutrition and Metabolism Laboratory.

In addition, June Tester, MD, MPH, a researcher at

CHORI and co-director of Healthy Hearts, is researching
how children respond to healthy snack options in their
neighborhoods and how a revitalized urban playground
affect children’s physical activity levels.

Children’s Hospital research helps Healthy Hearts program
Ronald Krauss, MD
Cardiovascular Lipid Laboratory
Bruce Ames, PhD
Nutrition and Metabolism Laboratory
Ronald Krauss, MD Bruce Ames, PhD
Children’s basic science researchers are collaborating
with Healthy Hearts clinicians in two particular areas
of research, aided by use of modified ion mobility
spectrometry (IMS), an ultra-sensitive way to
distinguish different kinds of molecules.
The team in Dr. Krauss’ lab is using IMS to
determine how to assess the risk of cardiovascular
disease in children, including those seen by Healthy
Hearts clinicians, and how to use what they find to
guide prevention and treatment of these diseases.
The Krauss team—in collaboration with the
Nichols Institute of Quest Diagnostics—has identified
a metabolic disorder, atherogenic dyslipidemia (AD),
that is associated with childhood obesity, hypertension
and type 2 diabetes. AD is becoming increasingly
common in children, especially those from minority
communities.
Discovering AD is also an example of how the
Krauss lab’s work is teaching us more about the
wide variety of high and low density lipids found in
humans. Learning what these lipids do and how they
affect cardiovascular health is essential to developing a
deeper understanding of how what we eat and how we
metabolize it affects our relative cardiovascular health.
Meanwhile, the Ames team is collecting data from
75 obese children, many of whom have been seen by
Healthy Hearts clinicians, to learn how their diets may
lead to nutrient deficiencies and increasing insulin
resistance.
Insulin resistance is a measure of how well someone
is able to metabolize glucose, the body’s basic fuel.
As insulin resistance increases, a child’s probability
of developing type 2 diabetes or heart disease also
increases.
The Ames team is finding that overall, the children
from whom they’re collecting data have a poor diet, and
w w w. c h i l d re n s h o s p i t al oa kla nd.or g • 15
the worse the diet the more insulin resistance the child
shows.
Their median intake of saturated fat—mostly
from fast foods—is about 2½ times higher than the
recommended daily allowance and their median intake
of refined carbohydrates (from soda, other sugar-
sweetened drinks and processed snacks) is about double
the allowance. At the same time the median amount
of fiber these children are eating is about half what’s
recommended.
Children’s research shows that lifestyle counseling—
like that provided by Healthy Hearts clinicians—can
help children eat fewer harmful foods and lose weight,
but that enormous barriers, including cost and limited
access to healthy foods, make it difficult for them to get
an optimal diet.
Research also shows how difficult it is to keep their
new weight stable by maintaining lifestyle changes.
That’s why the Ames lab has worked hard to develop
a new low-cost, low-cal nutrient-dense food supplement
that could help these children improve their nutritional
status and health.
Pilot studies of the “Ames bar”—in collaboration
with the Krauss lab—show that eating it leads to
favorable changes in lipids and cholesterol, as well as
other anti-atherogenic, heart-healthy effects, including
reduced inflammation levels and improved immunity.
Healthy Hearts will collaborate with the Ames lab
this summer on a pilot study measuring how eating the
Ames bar in combination with lifestyle counseling may
affect the health of children in the clinic’s program.
16 • C HI LD REN’ S HOS PITAL & R E SE ARCH CE NT E R OA K L A N D
Research
Children’s Hospital research supports the need for vitamin D
supplementation in groups at high risk of deficiency
Joyce C. McCann, PhD
Center for Nutrition and Metabolism
Bruce Ames, PhD
Nutrition and Metabolism Laboratory
Joyce C. McCann, PhD Bruce Ames, PhD
Researchers Joyce C. McCann, PhD, associate staff
scientist, and Bruce N. Ames, PhD, senior scientist, at
Children’s Hospital Oakland Research Institute have
found ample evidence to suggest an important role
for vitamin D in brain development and function.
Their conclusion, based on extensive research:
supplementation for groups chronically low in vitamin
D is warranted.
Their analysis was published in April 2008 in the
Federation of American Societies for Experimental Biology
(FASEB) Journal.
Vitamin D has long been known to promote
healthy bones by regulating calcium levels in the body.
Lack of sufficient vitamin D in very young children
results in rickets, which can be easily prevented by
vitamin D supplements. Only recently did the scientific
community become aware of a much broader role
for vitamin D. For example, we now know that, in
addition to its role in maintaining bone health, vitamin
D is involved in differentiation of tissues during
development and in proper functioning of the immune
system. In fact, over 900 different genes are now known
to be able to bind the vitamin D receptor, through
which vitamin D mediates its effects. In addition
to protecting against rickets, evidence now strongly
indicates that a plentiful supply of vitamin D helps to
protect against fractures in the elderly. Evidence also
continues to accumulate suggesting a beneficial role for
vitamin D in protecting against autoimmune diseases,
including multiple sclerosis and type I diabetes, as well
as some forms of cancer, particularly colorectal and
breast.
Many vitamin D experts advise that the currently
recommended level of vitamin D intake is much too low
and should be raised to protect against bone fractures
and possibly cancer in addition to rickets. Indeed,
even using present guidelines, too many Americans
have low vitamin D blood levels. Drs. McCann and
Ames propose that, despite uncertainty regarding all
of the deleterious effects of vitamin D inadequacy, the
evidence overall indicates that supplementation, which
is both inexpensive and prudent, is warranted for groups
whose vitamin D status is exceptionally low, particularly
nursing infants, the elderly, and African Americans.

Dr. Viteri’s research on iron supplementation changes World Health
Organization’s recommendations for pregnant woman
Fernando Viteri, MD
Center for Nutrition and Metabolism
Fernando Viteri, MD
A Children’s Hospital Oakland
Research Institute scientist, Fernando
Viteri, MD, ScD, has led a quiet
revolution that is changing the way
iron deficiency and anemia, that
affects more than 50 percent of
pregnant women, is addressed.
Iron deficiency has significant
negative impact on all populations,
but in pregnant women in particular,
iron deficiency—especially during
the first and second trimesters—can
cause premature delivery, low birth
weight, even a mother’s death if
anemia is severe. As a result, iron
supplementation has long been
recognized as a therapeutic tool for
treating iron deficiency and anemia,
especially in pregnant women.
The World Health
Organization (WHO) had been
encouraging therapeutic daily iron
supplementation, but Dr. Viteri’s
research suggests preventive weekly
iron-folate supplementation prior
to and during pregnancy is more
appropriate and safer for mothers and
their babies.
There are more than 100 papers,
from Africa, Asia, Europe, Latin
America, western Pacific and the
United States, several authored or
co-authored by Dr. Viteri, showing
weekly doses are effective in improving
iron reserves and even correcting
moderate anemia.
“Children, from infants to
adolescents, as well as women of
reproductive age the world over,
pregnant or not, are particularly at
risk of iron deficiency and the anemia
it causes and we must prevent it from
occurring,” said Dr. Viteri. Moreover,
the therapeutic approach often involves
large daily doses of iron that actually
have negative consequences to mothers
and to the outcome of pregnancy.”
Results of Dr. Viteri’s study in
collaboration with scientists at the
National Institute of Perinatology in
Mexico on hemoglobin concentrations
and pregnancy outcomes in non-
anemic women, published in the
Archives of Medical Research are very
compelling.
This study showed for the first time
that daily iron-folate supplementation
at the iron doses recommended for
pregnant women in iron-deficient
populations by WHO and the
Centers for Disease Control (CDC) is
significantly correlated with a greater
risk of low birth weight and premature
delivery–due not to iron deficiency, but
to iron excess and high hemoglobin
levels, which epidemiologic studies
have shown carry equal if not greater
outcome risks.
“What happened was that
hemoglobin went up and up, so that
by the end of the second trimester of
pregnancy, 27 percent of the women on
60 mg of iron a day had hemoglobin
levels that were undesirably high,
increasing the risk of low birth weight
and of premature delivery by four times
in those women, compared to women
receiving weekly iron doses (120 mg),”
explains Dr. Viteri.
This strongly suggests that the
recommended daily iron doses are too
w w w. c h i l d re n s h o s p i t al oa kla nd.or g • 17
high. As Dr. Viteri points out, “More is
not always better.”
Recent publications by him and
several collaborators also show that
daily therapeutic doses of iron prior to
and during pregnancy result in “free
radicals and oxidative stress” that lead
to cellular and DNA damage.
More may not be better, but
right timing is best, according to Dr.
Viteri. Recent research indicates the
important moment in pregnancy for
iron supplementation is early, not mid
pregnancy where it had been previously
recommended.
“It’s too late then, “ Dr. Viteri said.
In fact, his research in Vietnam suggests
weekly iron supplementation before
and during pregnancy significantly
improves its progress and its outcomes.
The World Health Organization
agrees: it now recommends women
who may become pregnant, and who
are low income, should take 50 iron
and folate tablets a year—one per week.
If they should then become pregnant,
they will enter pregnancy with good
iron and folate levels.
This can be done, Dr. Viteri points
out, for about 7 cents a year per person,
a small investment with big public
health benefits.
But Dr. Viteri’s work doesn’t end
in the laboratory. It includes finding
innovative community-partnerships to
help deliver the message and distribute
the iron-folate supplements to poor or
rural communities all over the world.
From Southeast Asia to the Philippines
and Central America, healthier
communities are being built one iron-
folate tablet at a time thanks to Dr.
Viteri’s efforts.
18 • C HI LD REN’ S HOS PITAL & R E SE ARCH CE NT E R OA K L A N D
Research
Dr. King’s research on pregnant women helps us understand the health
outcomes of their babies
Janet King, PhD
Center for Nutrition and Metabolism
Janet King, PhD
Janet King, PhD, senior scientist at Children’s
Hospital & Research Center Oakland, began
studying the nutritional needs of pregnant women
in graduate school. She started with a study of the
protein requirements of pregnant teenagers to see
whether the growing teens met their increased protein
requirement during pregnancy. The data from her first
study eventually became the basis for the U.S. and
international protein recommendations for all pregnant
women. Those recommendations remain in effect
today: Pregnant women are encouraged to consume an
additional 10 grams of protein a day. This can be found
in about 1½ ounces of meat or 1¼ cups of milk.
In the 1970s, when Dr. King started researching
nutrition during pregnancy the primary problem was
low birth weight. By the late 1990s, the picture had
changed. Obstetricians were now concerned about
babies being born too large—weighing more than eight
pounds, twelve ounces.
So Dr. King started studying obese pregnant women,
in the hopes of shedding light on how to prevent obesity
in their unborn children. If it can be prevented in utero,
it would save a lot of effort and resources later and be
far healthier for baby and mom.
When she came to Children’s in 2003—after a stellar
career in nutrition research spanning three decades—Dr.
King already knew that obese women are prone to
developing diabetes during pregnancy, which can lead to
overfeeding the baby in utero.
“We’d found that obese pregnant women given a
low-glycemic meal had lower blood glucose levels after
the meal,” said Dr. King. “I thought that maybe eating
a low-glycemic diet could reduce birth weight and
diabetes in obese women.”
This is the study that Dr. King and her team are
engaged in currently.
International efforts
While overweight babies remain a subject of Dr.
King’s research in the U.S., babies in Vietnam have the
opposite problem: low birth weight. She and a graduate
student recently returned from there working on a
project to improve pregnancy outcomes in underweight
women.
“In Vietnam, women have no social status within the
family unit,” Dr. King explained. “Even while pregnant,
 w w w. c h i l d re n s h o s p i t al oa kla nd.or g • 19

women are expected to work hard, both at home and
in the fields, while receiving the least amount of food
in the family, leading to underweight babies, which are
more vulnerable to disease.”
The Vietnamese government runs a program known
as VAC—“Vuon” means “garden or orchard,” “Ao”
means “fish pond,” and “Chuong” means “livestock
shed”—to help poor families improve their diets. The
government gives farmers land on which to grow VAC
products, in addition to the ubiquitous rice.
“The Vietnamese government has agreed to
encourage pregnant and lactating women to eat more
VAC food,” explained Dr. King. “We’ll buy fish,
chicken, and duck eggs from VAC farmers, make them
into little cakes, and deliver them to pregnant women
during their breaks in the rice fields. We are hoping to
demonstrate that consumption of these cakes will result
in better pregnancy outcomes and stronger children.”
By forging connections at the national level, Dr.
King’s research promises to have ramifications on
nutrition policy throughout Vietnam.
Dr. King is also engaged in nutrition research
projects in Mexico, South Korea, Bangladesh and
Senegal.
with more physical and psychological problems related
to living with obesity for such a long time. Reducing
BMI in teens has been a challenge.” The HEAL
Program successfully reduced blood pressure in teens, a
step in a positive direction.
USDA Guidelines
In 2005, Dr. King served as chair of the U.S. Dietary
Guidelines Advisory Committee. Appointed by the
federal government each year, this committee is charged
with reviewing the current science and developing
recommendations for national dietary guidelines. Next
time you are at the grocery store, look for the colorful
MyPyramid, which the USDA developed as a nutrition
education tool based on the 2005 guidelines.
Working locally and internationally, Dr. King
and her team are making a difference, not only to
the individuals who participate in a study or receive
treatment at Children’s, but to entire populations
affected by the nutrition-related policies that their
research informs.

Health Eating Active Living

When Dr. King first arrived at Children’s Hospital,
Bertram Lubin, MD, then senior vice president
of research, asked her to design a program to treat
childhood obesity. With the help of Children’s
primary care physician Lydia Tinajero-Deck, MD,
Dr. King founded Children’s Healthy Eating Active
Living (HEAL) program. HEAL was a clinic staffed
by medical doctors, dietitians, and exercise specialists,
who work with children and their families to develop
healthy eating choices, active living habits, and an open
dialogue about body image and self-esteem. The clinic
worked with about 475 children and their families
and illustrates how Children’s research benefits clinical
practices.
“We’re most successful at reducing body mass index
(BMI) in children under the age of 12,” stated Dr.
King. “This is mostly because their food intake is well
controlled by their parents. We are still working on ways
to be more effective with adolescents, who come to us
20 • C HI LD REN’ S HOS PITAL & R E SE ARCH CE NT E R OA K L A N D

Research
Research about the Effects of Community Parks
OBJECTIVE:
June Tester, MD, MPH, from Children’s Hospital Oakland, is studying how the
revitalization of Elm playground is affecting children’s physical activity and play
in Richmond.
THE PROGRAM:
Physical activity and active play are important for children, and neighborhood playgrounds provide
opportunities for needed activity and engagement. However, many urban playgrounds remain unused
despite municipal attempts at updating play equipment. A non-profit organization called Pogo Park,
directed by Toody Maher, is gathering the support from the city, philanthropic organizations, and
community residents to completely redesign a run-down playground called Elm Playlot that is located in a
high-crime neighborhood of Richmond, Calif.

Dr. Tester, with funding from Robert Wood Johnson’s Active Living Research, has been looking at how
this playground redesign is impacting the community.This study has been assessing playground use and
using accelerometers to measure physical activity during children’s play. Additionally, this study is looking
at the broader effects on community, such as the incidence of crime around the playground before and after
revitalization. A household survey of residents around this playground (as well as a comparison playground)
has been conducted to measure the impact of this playground revitalization
on “social capital” of the neighborhood. This survey uses questions about
neighborhood cohesion among residents to better understand how much
neighbors trust one another or have a sense of collective community.

Robert Wood Foundation’s leadership has highlighted this project in

several ways, most notably in presentations to First Lady Michelle Obama.
Baseline data has all been collected, and will be repeated in 2011 after the
playground redesign is complete.

Girl wearing study’s accelerometer.

 w w w. c h i l d re n s h o s p i t al oa kla nd.or g • 21

Research about Mobile Neighborhood Vendors

OBJECTIVE:
June Tester, MD, MPH, from Children’s Hospital Oakland, is researching the
lack of nutritious foods available to inner city children and how street vendors
impact children’s snack choices after school.
THE PROGRAM:
Dr. Tester studies the food environment and how it relates to childhood obesity. With colleagues Barbara
Laraia and Irene Yen at the University of California, San Francisco, she has been leading two grants funded
by Robert Wood Johnson Healthy Eating Research that address the paucity of nutritious options for many
inner city children.
She conducted an observational study of the food environment around schools in Oakland’s Fruitvale
district, noting the presence of a variety of street vendors in the after-school environment and the large
number of junk food purchases children make.
Based on this, she conducted two pilot studies that explored the feasibility of using mobile food vendors,
popular in low-income neighborhoods, to increase children’s access to healthy food.
For one study, she worked with an ice cream truck vendor and added a healthy snacks menu to his
merchandise. This pilot was a success: during the intervention, a large proportion of the total purchases
were from the healthy snacks menu. Plans are underway for a follow-up study to expand this intervention
to three trucks in order to look at the effect of price manipulation for healthy items. The second feasibility
study looked at what happened when a fruit and vegetable vendor (frutero) was allowed to sell immediately
in front of a school entrance. During a two-week intervention period, 248 serving-size bags of cut fruit were
sold (mostly to children), and sales for nearby competing vendors of junk food actually dropped. Dr. Tester
is also interested in policy options that cities can undertake to create healthy vending policies. “We are
looking for ways that cities can create incentives for vendors to do the right thing,” she says.
22 • C HI LD REN’ S HOS PITAL & R E SE ARCH CE NT E R OA K L A N D

Community Healthy Hearts looks for community partners to support

what our patients learn in the clinic. These community
programs include a range of activities, such as bike
trips, cooking classes, an organic farmers market and a
community vegetable garden.

Healthy Hearts community initiatives
Cooking class
In March 2010, Healthy Hearts
partnered with an organization called
Kids Cooking for Life to offer a pilot
series of two cooking classes for our
patients. Patients learned how to make
healthy recipes then shared the meal
they prepared with each other and
their parents. Lessons also focused on
important nutrition points, such as
proper portion size.
Farmers Market
Healthy Hearts is affiliated with a
weekly farmers market at Children’s
Hospital Oakland operated by Phat
Beets. Phat Beets is a local organization
dedicated to providing affordable access
to organic fresh fruits and vegetables,
grains and legumes to North Oakland
families through wholesale pricing.
Healthy Kids Day Youth
Triathlon
Saturday April 17, 2010
Healthy Hearts partnered with
Endurance – A Sports and Psychology
Center, Inc., and the Downtown
Oakland YMCA to host and direct the
Healthy Kids’ Day Youth Triathlon.
Six weeks of triathlon training was
provided, beginning with an orientation
for youth and their families culminating
in a fun youth day. Youth practiced
swimming, biking, and running. Youth
of all skill levels attended this entry-level
triathlon event.
Community Garden
In a park adjacent to Children’s
Hospital Oakland Research Institute, a
community garden is about to bloom.
In collaboration with Healthy Hearts,
the hospital neighborhood, Phat Beets
Produce and Children’s Hospital
Oakland, high school students, under
guidance of professional growers, will
learn how to plant and cultivate organic
vegetables, herbs and fruit trees. The
garden will be a springboard to learning
about nutrition, healthy cooking and
eating.
Girls Running Program
Healthy Hearts has also partnered
with East Bay Girls on the Run.
The mission of Girls on the Run of
the Bay Area is to educate and build
confidence in young girls through
non-competitive, curriculum-based
running programs. Girls on the Run
of the Bay Area provides an innovative
running program for girls ages 8 to 13
that uses experiential learning to teach
very specific and well-defined social and
personal skills. The program culminates
in a non-competitive community
running event that gives the girls a
chance to shine and an overwhelming
sense of accomplishment. Girls on the
Run offers 10-week programs during
the fall and spring seasons. Volunteer
coaches engage the girls in games and
running-based workouts that encourage
emotional, social, psychological and
physical development. The girls meet
twice each week after school for a total
of 20 one-hour sessions.
w w w. c h i l d re n s h o s p i t al oa kla nd.or g • 23
CRECE soccer project
Central American Refugee Committee
(CRECE) is a grassroots self-help
organization which empowers and
assists Oakland’s Latino immigrant
community. CRECE provides
constructive activities for youth,
emergency food for families at risk
of hunger, ESL classes, employment
assistance, and health programs.
Healthy Hearts directly refers our
patients to this free soccer program and
gives health talks to their coaches.
DREAM PROJECT:
A National Program to Combat
the Obesity Crises
Head Start has been an incredibly
successful federal program that includes
parent involvement and provides
comprehensive education, healthcare,
and nutrition services to low-income
children. We see a need for a similar
federally subsidized after-school
program.
Since lack of access to recreation
programs and unsafe neighborhoods are
barriers to physical activity, let’s bring
a new program directly to our schools.
Low-income children are at highest risk
of developing obesity, and would benefit
tremendously from a program that
would help them reach their goal of the
recommended 60 minutes of moderate
to vigorous activity a day, offer
education focused on healthy eating,
provide a venue to give them homework
help that they need. The U.S. has
already proven a model to give at-risk
kids a “Head Start.” Why not complete
the need and provide a federal program
that would give them a “Strong Finish”?
Fighting
childhood
obesity
in Northern
California