PREADOLESCENT NUTRITION

BY: JENNIFER JO

YNER, ANGELA

WOLFENBERGER, &

CHRISTINA EDENFIELD

OBJECTIVES

o Did You Know? Interesting Facts and Statisticso BMI : Charts, Weight Ranges, BMI Rebound, and Factors that Influence

Body Mass Indexo Healthy People 2010 and RDI for School-aged childreno Nutrition-Related Disorders in Overweight & Obesity: Define, Risks, and

Multi-Component Pediatric Weight Management Treatmento Nutrition-Related Disorders in High Cholesterol: Monitor and Screening,

Lab Values, and Lowering Cholesterol and Improving Lipoprotein Levelso 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 REBOUNDo 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 5.5o Average rebound: occurring around 6-6.3 years of ageo Late rebound: occurring after age 7o 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 BMIo 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 BMIo 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 2010Objectives:

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/dayBoys: 2279-2152 kcal/dayPRO: .95 g/kg/day or approx. 34 g/dayCHO: 130 mg/dayFiber: 31 g/day for Boys; 26 g/day for GirlsFat: 25-35% of daily kcalCalcium: 1300 mg/dayIron: 12 mg/day for Boys; 15 mg/day for Girls

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.

NUTRITION-RELATED DISORDERS: OVERWEIGHT AND OBESE CHILDREN

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 1-2 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 short-

term 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 3-18 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:oHave a parent or other close relative with total cholesterol higher than 240 mg/dL;oHave a Family Hx of CVD prior to age 55 in men and 65 in women;oHave a certain medical conditions such as kidney disease, Kawasaki disease, or juvenile idiopathic arthritis;oAre overweight or obese;oHave 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

Acceptable: <170 <150 <110 <45

Borderline High: 170-199 150-199 110-129

High: >200 >200 >130 <35 *putschild 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: 120/86Labs: 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.

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