Childhood Obesity: More Than Just BMI

1. Childhood Obesity: More Than Just BMI Presented by: Erica Timmermann Dietetic Intern 2009 NTR 622 Case Study Seminar Julie Moreschi Spring 2009

2. Childhood Obesity • Obesity among children and adolescents is on the rise today and is a major health concern. • According to the NHANES survey from 1976-1980 and 2003-2006 showed that obesity has increased by: • 5.0 % to 12.4 % among children aged 2 to 5 years of age. • And a 6.5 % to 17 % increase among children aged 6 to 11 years old. [1] Centers for Disease Control and Prevention. Overweight prevalence. Available at website: http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/prevalence.htm. Assessed April 3rd 2009, 2009.

3. Illinois and Chicago Childhood Obesity Rates • In 2007 the state percentage of children obese in Illinois was 12.9% of children, while 15.7% of children were considered overweight in Illinois. • Rates among children living in the Chicago area in 2007 was 15.9% of children were obese, while 18.7% were considered overweight. [2] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results Illinois 2007 dietary behaviors percentage of students who were obese. Available at website: http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=507&loc=IL&year=2007. Assessed April 3rd 2009, 2009. [3] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results Illinois 2007 dietary behaviors percentage of students who were overweight. Available at website: http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=506&loc=IL&yeay=2007. Assessed April 3rd 2009, 2009. [4] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results chicago, il 2007 percentages of student who were obese. Available at website: http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=507&loc=CH&yeye=2007. Assessed April 3rd 2009, 2009. [5] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results chicago, il 2007 percentages of students who were overweight. Available at website: http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=506&loc=CH&yeye=2007. Assessed April 3rd 2009, 2009.

4. Childhood obesity is defined for children and adolescents aged 2 through 19 years of age as: • Overweight being defined as a BMI at or above the 85th percentile and lower than the 95th percentile. • Obesity being defined as a BMI at or above the 95th percentile for children of the same age and sex. [6] Centers for Disease Control and Prevention. Defining childhood overweight and obesity. Available at website: http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/defining.htm. Accessed April 5th 2009

5. Pathophysiology of Childhood Obesity • Excess fat accumulatesinchildren and adolescents when there is an increase in energy consumption and a decrease in energy expenditure due to a secondary lifestyle such as watching television or computer and video game use. [7] Schwarz SM. Emedicine from WebMD. Obesity. Available at http://emedicine.medscape.com/article/985333-overview Accessed April 5th 2009.

6. In those children and adolescents who are obese, there is a dysfunction in the gut-brain-hypothalamic axis by means of the ghrelin/leptin pathway. • This has been known to play a role in abnormal appetite control, which leads to an increase in energy intake. [7] Schwarz SM. Emedicine from WebMD. Obesity. Available at http://emedicine.medscape.com/article/985333-overview Accessed April 5th 2009.

7. Ghrelin and Leptin • Ghrelin is a hormone that stimulates hunger (appetite stimulate) while leptin plays a key role in regulating energy intake and energy expenditure (appetite depressor). • Ghrelin levels increase before meals and decrease after meals. It is considered the counterpart of the hormone leptin, which is the overall satiety signal. • Leptin is produced by fat cells and most obese people have higher leptin levels than normal because of a higher number of fat cells. [8] Wikipedia: the free encyclopedia: Ghrelin. Available at website: http://en.wikipedia.org/wiki/Ghrelin. Accessed May 2nd. [9] Wikipedia; the free encyclopedia: Leptin. Available at website: http://en.wikipedia.org/wiki/Leptin. Accessed May 2nd 2009. Adopted from DeepaHandu. Professors at BenU. Obesity Theory and Practice Application. Lecture 5: Childhood Obesity.

8. Ghrelin and Leptin • Leptin does not have the same satiety affect in obese individuals as it does in leaner individuals. • Leptin Resistance! • Ghrelin levels in the plasma of obese individuals are higher than those in leaner individuals. • Ghrelin does not decrease after a meal, it still very high which means it still stimulates appetite. [8] Wikipedia: the free encyclopedia: Ghrelin. Available at website: http://en.wikipedia.org/wiki/Ghrelin. Accessed May 2nd. [9] Wikipedia; the free encyclopedia: Leptin. Available at website: http://en.wikipedia.org/wiki/Leptin. Accessed May 2nd 2009. Adopted from DeepaHandu. Professors at BenU. Obesity Theory and Practice Application. Lecture 5: Childhood Obesity.

9. However, excess intake, decrease energy expenditure, and hormonal disorders do not completely explain excess weight gain. • Most overweight children and adolescents have a family history of overweight and obesity with at least one or two parents, whom are overweight. • Nevertheless, it is both genetics, environmental and behavioral factors that play a role,which will be discussed later. [7] Schwarz SM. Emedicine from WebMD. Obesity. Available at http://emedicine.medscape.com/article/985333-overview Accessed April 5th 2009.

10. Contributing Factors to Childhood Obesity • Such factors include: • Genetics • Behavioral factors such as: • Energy intake, physical activity, and sedentary behavior. • Environmental factors such as: • Home, school, and even childcare.

11. American Dietetic AssociationEvidence Based Library • Based on the American Dietetics Associations evidence based library, they have made a “map” outlining some of the plausible causes of childhood obesity and overweight status. • ADA- Factors Associated with Childhood Obesity https://www.adaevidencelibrary.com/topic.cfm?cat=2792 [10] American Dietetic Association: Evidenced based library. Factors associated with childhood overweight. Available at website: https://www.adaevidencelibrary.com/topic.cfm?cat=2792. Accessed April 5th 2009

12. C.W.

13. Patient Profile: CW • CW is an eight-year-old Hispanic male that was born on August 17th, 2000. • CW speaks fluent English, as this is his primary language. • He is attending school full time and is enrolled in the 3rd grade. • He has two older female siblings and two parents that have been divorced for four years now.

14. Living Arrangements • CW spends his afternoons at his mother’s house until 7 pm where the father will pick them up at this time. • The children then stay with their father until school the next day. • Weekends can vary as to which parent has the children. • CW’s mother is remarried and lives with her husband and her mother. • Father lives by himself.

15. Patient Profile: CW • Past Medical History: • Attention Deficient Disorder (ADD) • Diagnosed two years ago. • Current Symptoms: • Excessive thirst • Excessive hunger • Inability to pay attention • Tiredness • Sleep apnea • He has been tested for Diabetes since his symptoms indicate this, but the test came back negative after his fasting blood glucose was 93 mg/dL.

16. Diabetes and Childhood Obesity • Rates for childhood obesity and type two diabetes are higher than ever. • The accumulation of excess body fat, particularly in the visceral area, has the potential to reduce the sensitivity to insulin in skeletal muscle, liver tissues, and adipose tissues also known as insulin resistance. [7] Schwarz SM. Emedicine from WebMD. Obesity. Available at http://emedicine.medscape.com/article/985333-overview Accessed April 5th 2009.

17. Risk Factors for Type 2 Diabetes in Youth • Obesity: Risk for diabetes increase two times for every 20% of excess body weight. • Puberty: Insulin Resistance falls by 30% in early puberty. • Family History: T2DM is associated strongly with family history. • Ethnicity: More prevalent in some ethnicities/minorities. Adopted from DeepaHandu. Professors at BenU. Obesity Theory and Practice Application. Lecture 5: Childhood Obesity.

18. Weight History • CW has been overweight since birth tipping the charts at the 90th to 95th percentile. • Since his parents divorce when he was 4, his eating habits have only gone down hill and have become increasing worse.

19. Parent to Child Relationships • For CW, his underlying problem on his unhealthy eating habits and obese lifestyle has a great deal to do with his parents who have been divorced since he was four years of age. • A study that investigated the characteristics of the social environment and their potential risk on childhood obesity, found that lower social class status, lower expressive social support, and unmarried status of the caretaker were associated with a higher calorie intake and a higher weight for height score in the children being studied. [11] Gerald LB, Anderson A, Johnson GD, Hoff C, Trimm RF. Social class, social support and obesity risk in children. Pediatrics. 2006; 20(3):145-163.

20. Parent to Child Relationships Another study done by Strauss, investigated whether the association between the home environment and socioeconomic factors lead to the development of obesity and found that children who livedwith single mothers were significantly (P < .05) more likelyto develop obesity by the 6-year follow-up. [12] Strauss RS, Knight J. Influence of the home environment on the development of obesity in children.
Pediatrics. 1999 Jun;103(6):85.  

21. Parents Medical History • The parent’s have no past medical issues; however, his mother used to be overweight until having gastric bypass surgery a few years back and the father is within normal weight status. • Mother states that one of his siblings is reported to be within normal weight limits while the other is reported to be underweight.

22. Nutritional Data • Height: 5’0 feet • Above the 97th percentile for stature-for-age • Weight: 158pounds • Above the 97th percentile for weight-for-age • Taken at doctors office at the end of February • BMI: 30.8 • Above the 97th percentile for BMI-for-age • UBW: Varies since he is a child. • Gaining 1-2 pounds/month

23. Medications [13] Pronsky ZM. Food Medication Interactions, 14th ed. Birchrunville, PA: Food-Medications Interactions; 2006.

24. Lab Results

25. Typical Day for C.W.

26. Nutrient Analysis of a Typical Day • Based on the nutrient analysis: • Total caloric intake: 3400 kcals • Protein: 97.91 grams • Fat: 140 grams of fat • Sodium: 4,520 mg. • Vitamin and Minerals: most vitamins and minerals meet 100% of the recommended intake except Vitamin E. • Carbohydrates: 50% • 12.9 servings • 9 from simple carbohydrates • Protein: 11%. • 5.0 servings of lean protein sources • Fat: 38% • 23 servings • Fruit: 3.5 servings • Vegetables: 3 servings • Milk: 1 servings

27. Personnel Food Habits • CW eats breakfast and dinner at his mother’s house and lunch at school. • When the father comes to pick up the kids in the evening, he likes to “treat” the kids to a snack which is usually around 7:00 pm. • Ice cream

28. Personnel Food Habits • Mother states: • CW rarely skips a meal and will often eat late at night. • Food dominates his life and she worries that he has lost all control over eating. • Does not chew his food but simply swallow’s food whole. • Eats 3 solid meals a day with snacks but has seen him sneaking food into his bedroom or other areas of the house in order to eat more food.

29. Personnel Food Habits • CW has no known food allergies or cultural restrictions. • He will eat out at least 2 times a week at fast food restaurants. • Mother prepares most mealsandoccasional he will eat ethnic Hispanic foods at fathers house over the weekends. • Eating together rarely occurs as the mother prepares the food and lets the children eat for themselves. • Mother and father do all grocery shopping for CW.

30. Personnel Food Habits When meeting with parents together at the second visit without CW, RD determined that child will eat one thing at mom’s house and then tell father that he does not like that food when served at fathers house.

31. Current Diet Order • After meeting with the RD on March 2nd 2009, she prescribed the follow diet: • 1800-2000 kcal meal plan • 50% from complex carbohydrates • 25% lean protein • 25% from monounsaturated and polyunsaturated fat • Saturated fats: < 7-8% of fat calories • 20 grams of fiber per day.

32. Diet Recommendations • Education: • Family Based counseling techniques • Role of six food groups for growth, development as well as disease prevention. • Sources of energy dense foods and beverages. • Appropriate portions for children. • Role of Physical activity in health and weight management. • Nutrition Goals: • Aim for daily consistency in intake • Decreasing portion sizes • Screen time: 1 Hour per day • Physical activity: 60 minutes per day

33. 1800 Kcal Diet • 50% from carbohydrates = 900 calories/4 = 225 grams/15 = 15 servings. • Diet Recall = 13 servings (9 from simple carbohydrates) • 25% from fat = 450 calories/9 = 50 grams/5 = 10 servings. • Diet Recall = 23 servings • 25% from protein = 450 calories/4 = 112.5 grams /7= 16 servings • 5 servings from lean meats

34. Diet Rationale The diet rationale is appropriate based on current recommendations for treating pediatric obesity. Based on the American Dietetic Association Evidence Based Library, they recommend the use of a 1)Treatment Focus Plan • Dietary interventions • Physical activity interventions • Behavioral interventions • Adjunct therapies 2)Treatment Format Plan • Educating children and parents together versus child alone • Prescribed diet plan and nutrition education • Group versus individuals counseling • Peer counseling https://www.adaevidencelibrary.com/topic.cfm?cat=2795 [14] American Dietetic Associations Nutrition Care Manual. Treating childhood overweight. Available at website: https://www.adaevidencelibrary.com/topic.cfm?cat=2795. Accessed April 4th 2009 

35. Dietary Interventions Dietary Interventions include the use of: 1) Balanced macronutrient diets 1)By age Groups 2)Selected Diets 2) Altered macronutrient diets

36. Balanced Macronutrient Diets • Balance macronutrient diets are based on the child’s age group or selected diet approaches. • Based on CW’s age, the ADA evidence based library states: “A prescribed diet was considered to be macronutrient "balanced" if the macronutrient composition fell within DRI ranges: ‘Adults should get 45 percent to 65 percent of their calories from carbohydrates, 20 percent to 35 percent from fat, and 10 to 35 percent from protein. Acceptable ranges for children are similar to those for adults, except that infants and younger children need a slightly higher proportion of fat (25 %-40%).’ “ [15] American Dietetic Associations Nutrition Care Manual. Pediatric weight management: dietary interventions: Available at website: http://www.adaevidencelibrary.com/topic.cfm?cat=2939.Accessed April 4th 2009.

37. Selected Diet Approaches • Stop Light Diet 2) Food Guide Pyramid

38. StopLightDiet • The Stoplight Diet is ideal for those age 6 to 12 years of age as a dietary component commonly used in behavioral interventions. • The diet classifies food as green, yellow, and red; much like a stoplight. • The energy goals for this diet is around 900 to 1,300 kcal/day with daily recording of all food and drinks consumed. • According to the evidence library, they grade this with a 1, which is good. [16] Kirk S, Scott B, Daniels S. Pediatric obesity epidemic: treatment options. J Am Diet Assoc. 2005;105:44-51.

39. StopLightDiet • Green-light foods are low calorie, high fiber foods with no restrictions placed on how much to eat. • Yellow-light foods are viewed as those essential to a healthy, well-balanced diet, but because they are considered to be a higher nutrient density they are to be eaten in moderation. • Red-light foods are those that are high in fat or simple in sugars and are limited to no more than four servings per week and have to be eaten away from home. [16] Kirk S, Scott B, Daniels S. Pediatric obesity epidemic: treatment options. J Am Diet Assoc. 2005;105:44-51.

40. Food Guide Pyramid • Research on the pre-2005 Food Guide Pyramid focuses primarily on the use of the pyramid as an assessment tool, not as an intervention tool to treat overweight in children. • There is not enough research to judge the effectiveness of using the pre-2005 Food Guide Pyramid as an intervention tool to treat overweight in children. [17] American Dietetic Associations Nutrition Care Manual. What is the evidence to support the Food Guide Pyramid as an approach to limiting calorie/food intake in children? Available at website: http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=250051. Accessed April 4th 2009

41. Altered Macronutrient Diets • Low Fat • Altered Carbohydrates • Altered Protein [14] American Dietetic Associations Nutrition Care Manual. Treating childhood overweight. Available at website: https://www.adaevidencelibrary.com/topic.cfm?cat=2795. Accessed April 4th 2009 

42. Physical Activity • Receiving a grade score of one, the evidence based library indicates that “using a program to increase physical activity as part of a pediatric weight-management program results in significant improvements in weight status and adiposity in children and adolescents” [18] American Dietetic Associations Nutrition Care Manual. What is the effectiveness of using a program to increase physical activity as a part of an intervention program to treat childhood overweight? Available at website: http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=105. Accessed April 5th 2009 

43. Treatment Focus-Behavioral • Behavioral interventions include the use of family-based counseling that includes parent training as part of a multi-component pediatric weight management program which results in significant reductions in weight status and adiposity in children 12 years and younger. [19] American Dietetic Associations Nutrition Care Manual. What is the effectiveness of family-based counseling including parent training or modeling as part of a multicomponent pediatric weight management program to treat overweight in children (ages 6-12)? Available at website: http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=99Accessed April 5th 2009.  

44. Treatment FocusPrescribed Diet and Nutrition Education • It has been shown that including a prescribed diet plan as part of a multi-component weight-management program results in improvements in adiposity in children in both the short-term and longer-term (more than one year). [20] American Dietetic Associations Nutrition Care Manual. What is the effectiveness of using a prescribed dietary plan as part of an intervention program for child (ages 6-12) overweight? Available at website: http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=97. Accessed April 5th 2009.

45. Other Recommendations • Research has shown that eating dinner as a family has been associated with a more healthful diet; more fruits and vegetables, fewer fried foods, less soda, less fat and more micronutrients. • Furthermore, I would encourage the parents to be a role model in healthy eating behaviors as well as partaking in physical activities with the child. • Parental modeling for both healthy eating habits and physical activity has been shown to help shape children’s values, beliefs, and behaviors about healthy eating and engaging in physical activity. [21] Gillmann MW, Rifas-Shiman SL, Frazier AL, Rockett HR, Camargo CA Jr, Field AE, Berkley CS, Colditz GA. Family dinner and diet quality among children and adolescents. Arch Fam Med. 2000; 9:235-240. [22] Ritchie LD, Welk G, Styne D, Gerstein D, Crawford P. Family environment and pediatric overweight

46. Other Recommendations • I would recommend the parents to write a list of meals together that the child can eat within their household in order to provide the same meals/foods at each house. • Educate the father on ways to provide “treats” that are not foods, such as going for a walk or a movie, taking them to the park or the pet shop, etc.

47. Sample Meal Plan-1800 kcal Breakfast: 1 egg or ¼ cup egg substitute 1 slice whole wheat bread, toasted 1 tsp margarine 6 ounces of low fat yogurt 1 medium orange Lunch: 3 ounces of lean deli meat 1 ounce of low fat cheese 2 slices of whole wheat bread Lettuce, tomato, onion, etc 2 tsp mayonnaise 1 medium apple 1 ounce of light chips Dinner 5 ounces of grilled, broiled or baked boneless skinless chicken ¾ cup cooked rice 1 dinner roll (whole wheat) Steamed assorted vegetables 1 small salad with lettuce tomatoes, onions, and cucumbers 2 tbsp of low fat salad dressing 1 tsp margarine Snack 1 cup of skim milk 3 graham cracker squares ½ cup of unsweetened applesauce

48. Short Term Goals for C.W. and Parents • Aim for a healthy well rounded diet • Increase fruits and vegetables to three to five per day • Increase low fat milk consumption • Decrease fast food consumption by limiting to once per week • Decrease soda and sugary beverage consumption to once a week • Increase physical activity to one hour per day • Decrease TV viewing time to one hour per day • Have divorced parent’s work together in planning meals and grocery list in order to have the same foods at both homes. • Work on portion control • Work on having the parents pack the child’s lunch to school every day

49. Long Term Goals for C.W. and Parents • Weight Maintenance • Improved diabetic symptoms • Ability for CW to plan his own healthy meals • Want CW to know the difference between healthy vs. not so healthy foods so he can continue to maintain his weight into adulthood.

50. ADIME NOTE: Assessment • CW is considered to be at a moderate to high nutritional risk due to an excess of body weight for his height and age. • He is far above the 97th percentile when plotted on a growth chart for BMI for age. • He consumes large amounts of food and eats all throughout the day. • He has diabetic symptoms and although he tested negative for diabetes he could still develop diabetes if his eating patterns continue.