Pediatric Weight Management

Samantha Koonce, Dan Dickerson , Joshua Richmond

 Background of the Disease
Childhood Obesity
Occurrence of obesity in children has tripled in the last 30 years
Determined by BMI and compared with CDC growth charts
Overweight: 85-94th percentile
Obese: 95th percentile
Contributors:
Food choices
Less physical activity
Parental obesity/ eating habits
Genetics
Obese children are more likely to become obese adults
 Background of the Disease (cont.)
Psychological concerns:
Depression
Poor body image
Risk for eating disorders
Health consequences:
Insulin resistance/ T2DM
Hypertension
Asthma
Sleep Apnea
Fatty Liver
 Demographics of Affected Children
17% (1 in 5) children (aged 6-19) are obese

Childhood obesity disparities:

19.5% of African American children

21.9% of Hispanic children

14.7% of caucasian children

8.6% of Asian children

Children of low income households are at higher risk for obesity

 Pathophysiology
Childhood Obesity
Behavioral
Less physical activity due to increased screen time
Food choices; total energy intake > total energy expenditure
Environmental
Increased availability of low-cost, high fat convenience foods
Parents food preferences affect childrens preferences
Genetic
Parental obesity more than doubles risk of childhood obesity
Hypothyroidism
Growth hormone deficiency
 Pathophysiology (cont.)
Obstructive Sleep Apnea (OSA) secondary to obesity
Characterized by recurrent partial or complete obstruction of the upper-airway
Most common cause in children is hypertrophy of adenoids
Increased risk in overweight and obese children
Central adiposity increases load on chest wall, resulting in sleep disordered breathing
Deposition of fat around the pharyngeal airway increases upper airway collapsibility
Fatigue associated with OSA exacerbates obesity by decreasing activity
Patient Background
Patient has several S/S of sleep disturbances over past several years as
described by parents:
Breathing with mouth during sleep
Breathing stops for 10 seconds per episode
Snoring
Restlessness during sleep
Morning headaches
Difficulty concentrating at school
Dx: Obstructive sleep apnea (OSA) secondary to obesity and physical
inactivity
Anthropometrics
Age: 10

Height: 57

Weight: 52kg

BMI: 24.9

97th percentile

Obesity >95th percentile

Past relevant data
Birthweight of 10 lbs 5 oz; 23 length

Family history of T2DM

Possible gestational diabetes

Patient has gained about 10 lbs a year for

past several years
RDI for 10 year Old Female
Reference Height Weight Water EER CHO Fat PRO PRO
BMI (kg/m2) (in) (lbs) (mL/kg for (kcal/day) (g/day) (g/day) (g/day) (g/kg/day)
kids
>30kg)

17.4 57 81 35mL/kg 1458 130 --- 34 0.95

*Fat provides energy needed for growing children. Omega-3s are essential for
normal brain development in this age group. Fats should make up 25-35% of a 10
to 11 yr/o diet. This equates to about 50-70g of fat per day for children who eat
1,800 calories a day.
 Dietary history
Food and Nutrition Related History:
The patients activity levels is sedentary, and
often plays video games.
Generally has a good appetite.
Patient takes flintstones daily multivitamin
24-hr recall shows high intake of high sugary
beverages as well as high carbohydrate and
high fat snacks.
Actual calorie intake of 4581 kcal exceeds
the recommended intake by 2,510 calories.
 24 hour recall
Breakfast (1216 kcal): 2 breakfast burritos, 8 oz whole milk, 4 oz apple juice, 6 oz
coffee w/ C cream, 2 tsp sugar

Lunch (1199 kcal): 2 bologna sandwiches w/ cheese and 1 tbsp mayo each, 1-oz
pkg fritos corn chips, 2 twinkies, 8 oz whole milk

Snack : peanut butter and jelly sandwich (2 tbsp peanut butter, 2 tbsp jelly), 12 oz
whole milk

Dinner (1226 kcal): fried chicken (2 legs and 1 thigh), 1 C. mashed potatoes (w/
butter and whole milk), 1 c. fried okra, 20 oz sweet tea

Snack: 3 C. microwave popcorn, 12 oz Coca-Cola

 Diet Analysis
The patients diet consists of little to no activity with high fat,
high sugar, and high carbohydrate intake, putting her at risk for
T2DM, CVD, and metabolic syndrome.
Patients diet is void of fruits and vegetables.
Overall calories: 4581 kcal; contributing to unhealthy weight
gain/ fat distribution.
FAT intake: 214g
CHO intake: 510g
PRO intake: 161g
 The big
picture:
Fats provide 50% of her
calories vs. the
recommended 25-35% of
kcals

PRO is only slightly high

CHO percentage is
proportional to kcal eaten,
but total kcals eaten
exceeds limit for the
patient. Therefore, kcals
should be reduced to
have correct grams of
CHO consumed.
 Diet Prescription
Mifflin-Jeor Equation for overweight population
9.99 x wt(52kg) + 6.25 x ht(145cm) - 4.92 x age(10yrs) - 161 = 1,215.53
Times activity factor of 1.2 = 1,458.6 kcal
Significant research on predictive EER equations not available for adolescents.

PRO: .95 g/Kg = 50g per day

CHO: 130g per day
FAT: 50-70g per day
Fluid 35mL/kg = 1,820mL
Diet Prescription Continued ..
The patient is not on any medications, nor is she suffering from any diseases
other than sleep apnea, therefore no specific food restrictions will be made.

Pt will be provided with a diet that follows MyPlate.gov Guidelines

Half of the plate should be fruits and vegetables
Choosing reduced fat dairy products
Half of grains consumed should be whole grain
Varied lean protein sources
Portion control while still enjoying favorite food
Reductions in sugar intakes
Fun exercise activities will be added to her routine
Pertinent Lab Values and Significance
Possible contributing factors
Glucose (mg/dL) 112

Glucose - family Hx T2DM; HDL-C (mg/dL) 34

can lead to insulin
insensitivity later in life. LDL/HDL ratio 3.23

HDL-C - high intake of

saturated fat, low P.A.; can
lead to CVD.

LDL/HDL ratio - High intake of

saturated fat; high risk for
CVD.
Nutrition Dx
1) Physical inactivity, related to low energy level, secondary
to OSA, as evidenced by OSA diagnosis, PT, parent, and
teacher statements regarding cognitive/arousal level
decline congruent with exhaustion.
2) Excessive energy intake, related to food and nutrition
related knowledge deficit, as evidenced by BMI >97th
percentile, and 24-hour recall indicating intake of approx.
4500Kcal, 2.5 times her energy requirement.
Client Goals & Interventions: Physical Inactivity
Goal #1) Pt will increase physical activity to 3+ hours per week within 1 month.

Pt, along with her parents, will explore new ways to add physical activity to her
day, with the goal of finding 2 activities, at least one of which including an aerobic
component (running, swimming, hiking etc.) that she enjoys.

Goal #2) Pt will reduce screen time to one hour per day by the end of the week.

Pts parents should strictly monitor and enforce screen time limits, keeping in
mind a long term goal of achieving a 1:1 screen time to physical activity ratio.
Client Goals & Interventions: Excessive E. Intake
Goal #1) Pt will reduce daily caloric intake to below 2000Kcal within 2 months.

Pt, along with her parents, will thoroughly review all literature and supplemental
materials provided by RDN, and actively seek clarification when needed. Pt, with
the help and supervision of her parents, will strictly adhere to nutrition
prescriptions.

Goal #2) Pt will consume at least 8 servings of vegetables per day within 2 weeks.

Pt and her parents should shop for groceries together, with the goal of finding at
least 4 vegetables, fresh or frozen, that she enjoys eating when
prepared with minimal fat.
Monitoring
Anthropometrics: BMI, monthly weight, semi-annual height updates. (online calc
between appointments).

Bio: Lipids, HbA1c, glucose as ordered by physician, additional not necessary

Clinical: observe for cognitive/behavioral changes on subsequent visits. Inquire

about energy level from Pt, parents, and request teacher feedback as OSA
treatment progresses.

Dietary: food/activity/screen time/symptom journal for 90 days.

Pt, parents, dietitian should work together to devise format that will reduce burden
and provide non-food based reward system for proper upkeep.
Clinical Pearls: key take away
Parental involvement is key to successfully changing a childs life style

Involving children in food preparation enhances their interest in what they

consume.

Often times the parents behaviors must also change to show the child by
example

It is important to refrain from discussing body appearances with children, and

instead focus on become healthier versions of themselves.
References
1. AlOtaibi FN, AlOtaibi M, AlAnazi S, et al. Childhood and adolescent obesity: Primary Health Care
Physicians' perspectives from Riyadh, Saudi Arabia. Pakistan Journal Of Medical Sciences
2017;33(1):100-05 doi: 10.12669/pjms.331.12118[published Online First: Epub Date]|.

2. Huang H, Wan Mohamed Radzi CWJB, Salarzadeh Jenatabadi H. Family Environment and Childhood
Obesity: A New Framework with Structural Equation Modeling. International Journal Of Environmental
Research And Public Health 2017;14(2) doi: 10.3390/ijerph14020181[published Online First: Epub Date]|.

3. Luciano R, Shashaj B, Spreghini M, et al. Percentiles of serum uric acid and cardiometabolic
abnormalities in obese Italian children and adolescents. Italian Journal Of Pediatrics 2017;43(1):3-3 doi:
10.1186/s13052-016-0321-0[published Online First: Epub Date]|.

4. Narang, I., & Mathew, J. (2013). Childhood Obesity and Obstructive Sleep Apnea. Childhood Obesity,
145-163. doi:10.1201/b16340-10
 References (cont.)
5. https://www.andeal.org/topic.cfm?menu=5296

6. http://www.obesity.org/obesity/resources/facts-about-obesity/childhood-overweight

7. https://www.cdc.gov/healthyschools/obesity/facts.htm

8. https://www.cdc.gov/obesity/data/childhood.html