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OBJECTIVES
o
Did You Know? Interesting Facts and Statistics
o
BMI : Charts, Weight Ranges, BMI Rebound, and Factors that Influence
Body Mass Index
o
Healthy People 2010 and RDI for School-aged children
o
Nutrition-Related Disorders in Overweight & Obesity: Define, Risks, and
Multi-Component Pediatric Weight Management Treatment
o
Nutrition-Related Disorders in High Cholesterol: Monitor and Screening,
Lab Values, and Lowering Cholesterol and Improving Lipoprotein Levels
o
SOAP
DID YOU KNOW?
o 1 in 5 school aged children have up to 5 snacks per day.
o The average annual growth during school years is 7 lbs and 2.5 inches due to spurts
in growth and/or appetite.
o Children between the ages of 9-11 should have their lipid levels screened and again
between 17-18 years old.
o Childhood obesity has more than tripled in the past 30 years.
o
Nearly 40% of African American and Hispanic children are overweight or obese.
o The average American consumes 31% more calories and 15 more lbs of sugar a year
than in 1970.
o
8-18 year olds on average spend 7.5 hours a day using entertainment media such
as TV, computers, video games, and cell phones.
DID YOU KNOW CONTINUED…
o The psychological stress of social stigmatization affects self-esteem so greatly that
obese children are not learning as well as those who are not obese.
o Furthermore, physical fitness has been shown to be associated with higher
achievement.
o Children of parents who impose authoritarian control on their children’s eating
were less likely to be responsive to energy density. These children were unable to
listen to internal cues in energy regulation.
o
The more a mother is concerned with her own weight, the more likely she is to
employ restrictive child-feeding practices. This can actually promote the intake of
forbidden or restrictive foods causing the child to ignore internal cues of hunger
and satiety, thus running the risk of becoming obese or having an eating disorder.
BMI WEIGHT-FOR-AGE PERCENTILES BOYS: 2-20 YEARS OLD
BMI WEIGHT-FOR-AGE PERCENTILES: GIRLS 2-20 YEARS OLD
UNDERSTANDING BMI FOR SCHOOL- AGED CHILDREN
Underweight: <5%
Healthy weight: 5% up to 85%
Overweight: 85% to 94%
Obese: 95% and greater
BMI is calculated using your child’s weight and height and is then used to find
the corresponding BMI-for-age percentile for your child’s age and sex.
BMI-for-age percentile shows how your child’s weight compares to that of
other children of the same age and sex.
***BMI is not constant throughout childhood because height plays a
factor. This is why we use charts plotting with weight and age.
UNDERSTANDING BMI REBOUND
o BMI Rebound is the normal increase in body mass index that occurs after
BMI declines and reaches its lowest point, at about 4-6 years of age, and
is reflected in the BMI-for-age growth chart. Studies suggest that the age
at which BMI rebound occurs may have a significant effect on the amount
of body fat that the child will have during adolescence and into
adulthood.
o Early rebound: occurring before age 5.5
o Average rebound: occurring around 6-6.3 years of age
o Late rebound: occurring after age 7
o Those children who had an early BMI rebound were more likely to have
higher BMI’s as adolescents and adults compared to those children who
had an average or late BMI rebound.
FACTORS THAT INFLUENCE BMI
o Parents and older siblings have the most influence on a child’s attitude toward
food and food choices. Parents need to be positive role models for their
children in terms of healthy eating behaviors.
o Children who ate dinner with their families have a higher intake of energy and
nutrients, eating more fruits and vegetables and less fried foods or soft drinks.
o The area a family lives in can determine what foods are available at stores.
Supermarket access in suburban areas is associated with a reduced risk for
obesity ,while lower income or rural neighborhoods are located nearer to
convenient stores and fast food restaurants.
o Whether a child is breastfed or not; research has shown that breastfeeding
protects against childhood overweight and obesity. Only 13% of babies are
exclusively breastfed at the end of 6 months.
FACTORS THAT INFLUENCE BMI
o
The diet and weight of the mother while a baby is in utero has been found to be
the most significant predictor of childhood BMI; family income and cognitive
stimulation came next.
o
Consuming sugary drinks heavily influence BMI in school aged children. Soft
drinks and sweetened juices are now usually sold in 20 oz bottles. More than half
of US middle and high schools have vending machines and cafeterias that offer
sugary drinks.
o
Television and the media contributes to how much physical activity a child gets.
The American Academy of Pediatrics recommends that children have no more than
2 hours of screen time (associated with sedentary activity) each day, and that
televisions and other screens be removed from a child’s sleeping area. Each
additional hour of screen time increases the prevalence of obesity by 2%. Children
aged 11-13 years old have the highest rates of daily TV viewing.
o
In relation to television viewing, 40% of Saturday morning advertisements are
about food, of which 91% are for foods high in fat, sodium, or sugar.
HEALTHY PEOPLE 2010
Objectives:
o
Reduce overweight and obesity in children
o
Consume at least 2 servings of fruit and 3 servings of vegetables a day
o
Consume 6 servings of grains per day with 3 servings being whole grain
o
Consume no more than 30% calories from total fat, and less than 10% calories
from saturated fat
o
Consume no more than 2400 mg of Sodium per day
o
Meet RDI for Calcium
o
Increase Physical Education in U.S. public and private schools
o
Increase trips made by walking and bicycling
NUTRIENT NEEDS:2002 DRI FOR AGES 9-18
Girls: 2071-2368 kcal/day
Boys: 2279-2152 kcal/day
PRO: .95 g/kg/day or approx. 34 g/day
CHO: 130 mg/day
Fiber: 31 g/day for Boys; 26 g/day for Girls
Fat: 25-35% of daily kcal
Calcium: 1300 mg/day
Iron: 12 mg/day for Boys; 15 mg/day for Girls
NUTRITION-RELATED DISORDERS:
OVERWEIGHT AND OBESE CHILDREN
o Overweight is defined as having excess body weight for a particular height
from fat, muscle, bone, water, or a combination of these factors. Obesity
is defined as having excess body fat.
o Overweight and obesity are the result of “caloric imbalance”- too few
calories expended for the amount of calories consumed.
o Overweight children are usually taller, have advanced bone age, and
experience sexual maturity at an earlier age than non-overweight
children.
o Children who have a BMI above the 85th percentile and who have other
health risks should be monitored for type II DM beginning at the age of 10
or at puberty.
HEALTH RISKS FOR OBESE CHILDREN
o Immediate health effects- Obese youth are more likely to have risk factors
for CVD, such as high cholesterol or high blood pressure; they are more
likely to have pre-diabetes. They are also at a greater risk for bone and
joint problems, asthma, sleep apnea, gallstones, fatty liver, reflux, and
social and psychological problems. In one study, 70% of overweight and
obese children had one risk factor for CVD while 39% had two or more
risk factors.
o Long-term health effects- Obese children are more likely to be obese
adults having the greater risk for heart disease, stroke, type II DM, cancer,
and osteoarthritis. Cancer types involved in the greater risk includes
breast, colon, endometrium, esophagus, kidney, pancreas, gall bladder,
thyroid, and cervix to name a few.
TREATMENT FOR CHILDHOOD OVERWEIGHT AND OBESITY
To treat with weight maintenance or weight loss:
- If child falls in the 85th-94th percentile the child may maintain weight.
- If the child falls in the 95th to 98th percentile the child may lose weight at 12 lb per month until the BMI-for-age drops to <85th percentile.
- If the child is in the 99th or greater percentile the may child lose weight at a
rate of no more than 2 lbs per week until the BMI-for-age drops to <85th
percentile.
Through Energy Restriction:
- A balanced macronutrient diet of 900-1200 kcal per day can help with shortterm and long-term weight loss to improve weight status and body
composition in children ages 6-12 years old.
***Do not place child on weight reduction without consulting a healthcare
professional such as a Registered Dietitian.
MULTI-COMPONENT PEDIATRIC WEIGHT MANAGEMENT
Nutrition Education that is Family-Based Works Best and Includes 1) Nutrition, 2)
Physical Activity, and 3) Behavior Intervention by Assessing 5 Parts:
1. Food
•
Decrease the intake of fats and sweetened beverages
•
Increase fruit and vegetable intake; meet RDI for Calcium
2. Child and Diet Behavior
•
Decrease highly palatable foods, foods away from home, and portions; do not skip
breakfast
3. Physical Activity
•
Decrease sedentary activity associated with TV, video games, and computers
•
Participate in sports; play outside before and after dinner; physical education at
school
PWM CONTINUED…
4. Determinant of TEE
•
If possible, RMR should be measured (eg , indirect calorimetry); If not use:
TEE= 114 – (50.9 x age/yrs) + PA [ (19.5 x wt/kg) + (1161.4 x ht/m) ] for Overweight Boys age
3-18 years old in PWM
TEE= 389 – (41.2 x age/yrs) + PA [ (15 x wt/kg) + (701.6 x ht/m) ] for Overweight Girls age 318 years old in PWM
PA= 1.0 for sedentary; 1.12 for low active; 1.24 for active; 1.45 for very active
5. Family Climate Factors
•
Lack of parental controls and restraint; lack of parental concerns about weight status
•
Reduce weight problems with family cohesion, democratic parenting style, parental
support, and cognitive stimulation at home
* Be aware of household food insecurity.
* Have an individualized Nutrition Rx by a healthcare professional such as a RD.
NUTRITION-RELATED DISORDERS:
MONITORING & TREATING HIGH CHOLESTEROL
Children 2-8 and 12-16 years old should be screened if they:
o Have a parent or other close relative with total cholesterol higher
than 240 mg/dL;
o Have a Family Hx of CVD prior to age 55 in men and 65 in women;
o Have a certain medical conditions such as kidney disease,
Kawasaki disease, or juvenile idiopathic arthritis;
o Are overweight or obese;
o Have additional risk factors such as DM, high BP, or smoking
cigarettes.
CHOLESTEROL & LIPOPROTEIN LEVELS
Cholesterol mg/dL
TG mg/d
LDL mg/dL
HDLmg/dL
<45
Acceptable:
<170
<150
<110
Borderline High:
170-199
150-199
110-129
High:
>200
>200
>130
<35
*puts
child at
risk for
heart disease
*** Children with LDL levels above 130 mg/dL should receive individual
nutrtional counseling that focuses on reducing dietary fat and cholesterol
along with increasing physical activity; rescreen lipid profile after 3-6
months of lifestyle intervention.
WAYS TO LOWER CHOLESTEROL AND
IMPROVE LIPOPROTEIN LEVELS
o
Eat a diet rich in fruits, vegetables, and whole grains.
o
Choose from a variety of protein foods, including lean meats and poultry, fish,
nuts, beans, peas, and soy products.
o
Keep dietary fat RDI appropriate: Total fat between 25-35% of kcal, Saturated fat
<10% of kcal, and Trans fats <1% kcal.
o
Limit Cholesterol to 300 mg or less per day.
o
Choose nonfat or low-fat milk and dairy products.
o
Stay away from solid fats. Use plant oils and soft margarine.
o
Limit beverages and foods with added sugars.
o
Limit commercially prepared foods like baked goods.
o
Aim for 60 minutes of physical activity a day!
SOAP
S: Patient’s mother states there is a family history of
cardiovascular disease, hypertension and stroke.
Patient has not reached menarche. Mother indicates
patient is sedentary, unlike active normal weight
siblings. Parents have a history of overweight. Family
eats out 3-4x/week. Mother is concerned about
patient’s body image and self-esteem. Patient is
middle child of 6 children.
O: 10 year, 2 month old female
Ht: 60.5” (>95th percentile) wt: 180# (>99th percentile)
BMI: 34.6 (extremely obese); based on CDC chart for female
children/adolescents, patient should weigh less than 104lbs
(85th percentile).
BP: 120/86
Labs: Chol:208 Trig:157 HDL:54 cLDL:122.6
fbg:81 Hg: 13.4
EER: 2082 kcal/day at healthy BMI
A: (NI-1.3) Excessive Energy intake RT high intake of high
fat and sweetened convenience foods AEB BMI >99th
percentile and estimated energy intake >3700kcal/day
based on 24 hour recall compared to recommended
2082kcal at a healthy weigh.
(NB- 2.1) Physical Inactivity RT sedentary behavior AEB
BMI >99th percentile, preference for reading, and
infrequent physical activity.
P: (ND 1.2 10830) Energy Modified diet to incorporate nutrient-dense foods, and
decrease energy density with use of reduced kcal meals and snacks (1200 kcal/day
for wt loss). Limit fat intake to <30% of daily calories and saturated fat to <10% of
daily calories. Have patient keep food and exercise journal to monitor kcal intake
and minutes of physical activity.
(RC 1.6) Referral to community Agency/Program –Encourage enrollment in sports
programs (soccer, basketball, swimming, etc), exercise therapy, and/or fitness
centers with programs for adolescents.
(E 1.1) Nutrition education of patient/family on recommended patient diet to include
portion control, energy balance, improved fast food choices, healthy meals/snacks,
and health risks of chronic obesity. Teach family to prepare healthy snacks to take
to sports activities, and to avoid concessions at games. Encourage outdoor play
and sports practice with siblings.
Monitor: (FH 1.1) Energy Intake with goal of initially reducing weight by 10%
(18 lbs) within 9-12 weeks.
(FH 1.5.1) Fat and Cholesterol Intake with a goal of decreasing intake of total
and saturated fat to <30% of daily calories. Repeat lipid labs in 12 weeks.
(AD 1.1.5) Body Mass Index with goal of ultimately lowering BMI to at or
below 85th percentile. (below 113lbs at age 11, height 62”, assuming
normal growth for age of 2”/year)
(PD 1.1.3) Cardiovascular-pulmonary reduce blood pressure and blood lipids
to within normal limits (BP < 120/80, Total Chol < 200)
See patient again in one month to review journal and evaluate diet plan
adherence. Suggest weekly group visits for family/patient support for at
least 8-12 weeks (initially). Repeat labs in 3 months.
PATIENT’S TYPICAL DAILY INTAKE
o Breakfast: 3 pancakes with butter/syrup, 2 sausage links, and 8oz whole milk
o School: 8oz whole milk at milk break; school lunch with 8oz whole milk
o After school snack: potato chips w/ soda pop, or cookies w/ soda pop
o Supper: Super nachos at basketball game (meat, cheese, chips, sour cream) or
chili dog, 1 individual bag of chips, and 12 oz soda
o Snack: 3c microwave popcorn
o Calories >3700 (school lunch unknown, but estimated at approximately 650+
kcal, which is typical for a school lunch), grains (mostly refined) 10+ oz, 2 cups
vegetables, 0 cups fruit, 5 cups whole milk, 3+ oz protein, 1067+ empty calories
SUGGESTED MODIFIED DIET EXAMPLE
o Breakfast: 1/2 whole wheat English muffin , 1 tablespoon peanut butter , and 1
cup nonfat milk or 6 oz light yogurt
o School: 8oz skim or 1% milk at milk break; school lunch with 8oz skim or 1% milk
o After school Snack: 1 cup blueberries , 1 oz cubed cheese, and bottled water (can
add a zero calorie flavoring)
o Snack—Take to basketball game: 1 peach, apple, or nectarine and 12 oz diet
soda
o Supper: ½ cup cooked whole grain pasta, 1/2 cup tomato sauce , 1 cup grilled
vegetables (pepper, carrot, onion, eggplant) , and 1-2 cups green salad (mixed
lettuce, cucumber, green pepper, celery) with vinegar and lemon juice or 2 tbsp
low calorie dressing
o Targets: Calories approx. 1200 kcal, 6 oz grain, 2 ½ cup vegetables, 1 ½ cup fruits,
3 cups dairy, 5 oz protein, 1 hour of moderate activity exercise (playing outside,
swimming, yoga, team sports) daily. Limit screen time to <1 hour/day.
REFERENCES:
Barlow, Sarah et al., Expert Committee Recommendations Regarding Prevention,
Assessment, and Treatment of Childhood and Adolescent Overweight and Obesity:
Summary Report, Pediatrics, Dec 2007; 120 (4): S164-192.
Brown, JE, Nutrition Through the Life Cycle, 4th Edition, Wadsworth Cengage Learning,
2011.
“Cholesterol and Your Child”, http://kidshealth.org/parent/medical/heart/
/cholesterol.html, retrieved on October 12, 2012.
“Health Problems and Childhood Obesity”, http://www.letsmove.gov/healthproblems-and-childhood-obesity, retrieved on October 19, 2012.
Hipsky J, Kirk S, Healthworks: Weight Management Program for Children and
Adolescents, Journal of the American Dietetic Assoc., 2002; 102: S64-67.
Kohn, Michael, Rees, Jane, et al, Preventing and Treating Adolescent Obesity: A
Position Paper of the Society of Adolescent Medicine, Journal of Adolescent
Health, 2006; 38: S784-787.
Mahan LK, Escott-Stump S, and Raymond JL, Krause’s Food and the Nutrition Care
Process, 2012. Elselvier, 13th Edition.
“Normal Triglyceride Levels for Children”, http://www.livestrong.com/article/408579normal-triglyceride-levels-for-children/, retrieved on October 15, 2012.
“Overweight and Obesity”, http://www.cdc.gov/obesity/childhood/ solutions.html,
retrieved on October, 15,2012.
Sothern, M, Schumacher, A, et al, Committed to Kids: an Integrated 4-level Approach
to Weight Management in Adolescents, Journal of the American Dietetic Assoc.,
2002; 102: S81-85.