Pediatric Overweight: Assessment and Intervention Module Objectives:
Demonstrate how to obtain dietary information from pediatric patients. Provide advice to parents on healthy food choices and feeding practices. Evaluate physical activity in children and make appropriate recommendations. Implement appropriate interventions for preventing and treating pediatric overweight.
Module Outline:
Diet Assessment Nutrition Assessment: Introduction Dietary Habits Assessment Diet Assessment in Children Screening Tools: Overview Screening Tools: Family Eating Habits Quiz Food Group Assessment Tool Interpreting the Food Group Assessment Case Practice: Dietary Assessment Healthy Food Choices Nutrition Basics: Food Groups Serving Sizes Portion Size Evolution Over Time Variety and Moderation Go, Slow, and Whoa Foods Beverage Choices Case Practice: Dietary Interventions Healthy Feeding Practices Breastfeeding as a Prevention Strategy Internal Cues Setting Limits Parental Role Modeling Nutrient Density Nutrient vs Energy Dense Foods Establishing Food Preferences Understanding Food Preferences Promoting Healthy Weight Activity Assessment Quantifying Physical Activity Assessing Physical Activity in Children Evaluating a Child's Activity Level Additional Factors in the Physical Activity Assessment Case Practice: Physical Activity Assessment Activity Recommendations How Much Activity is Enough? Activity Level Classifications Pediatric Overweight: Assessment and Intervention Handouts 1
Nutrition Guidance: Active Kids Nutrition Guidance: Active Teens Value of Less Sedentary Time Ways to Promote Physical Activity Intervention Strategies Prevention and Treatment: Current Status The Physician's Role Medical Assessment Communicating With Families Key Elements of a Weight Management Program Setting Appropriate Goals Counseling Steps Weight Management Effective Weight Management Strategies: Nutrition Effective Weight Management Strategies: Physical Activity Drawing Up an Intervention Plan Motivational Interviewing Motivational Interviewing: An Introduction Motivational Interviewing: Principles Motivational Interviewing: Common Elements Weight Loss Diets Aggressive Dietary Intervention Popular Weight Loss Diets Pharmacological Therapy Pharmacotherapy for the Pediatric Population Pharmacotherapy: Orlistat Pharmacotherapy: Sibutramine Surgical Intervention Surgical Intervention: Overview Bariatric Surgery: Indications and Contraindications Special Concerns: Adolescents and Bariatric Surgery Restrictive Procedures: Nutritional Impact Combined Procedures: Nutritional Impact Common Nutrient Deficiencies Dietary Modifications Following Bariatric Surgery Health Outcomes
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Objectives, Key Concepts, and Key Concept Summaries by Topic
Topic: Diet Assessment Objective: Demonstrate how to obtain dietary information from pediatric patients. Key Concept: Diet assessment is a key part of any nutrition evaluation. A diet assessment should provide information about the patient's intake with regards to food choices, calorie level, variety, adequacy, portion sizes, potential excesses or deficiencies, and dietary supplement use. There are many ways to assess a diet in research settings or in consultations with a dietitian (i.e., food frequency questionnaire, 24-hour recall, food record), however, most practitioners use some type of brief dietary screening tool to quickly identify problem areas. Many tools can be self-administered or administered by medical staff to save you time. ________________________________________________________________________ Topic: Healthy Food Choices Objective: List three things a physician can advise parents to do to improve the quality of a child's diet. Key Concept: Making healthy choices involves emphasizing nutrient-dense foods and appropriate portion sizes. Constructing a healthy diet begins with making appropriate food and beverage choices. The MyPyramid.gov website is one tool that may help individualize dietary recommendations for your patients, and the Go, Slow, Whoa classification system may be especially useful in guiding children, adolescents, and their families. The caloric contribution of beverages to the total diet should not be overlooked. Choosing nutrientrich beverages in moderation and using water to satisfy thirst is a reasonable approach as children often drink large amounts of sweetened beverages. Since portions have increased dramatically over the years, understanding age- appropriate serving sizes and controlling portion sizes are also crucial to balancing energy intake with expenditure. ________________________________________________________________________
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Topic: Healthy Feeding Practices Objective: List three healthy feeding practices for parents to implement with their children. Key Concept: Parental feeding practices and eating behaviors can influence their child's risk for overweight. Breastfeeding is one of the earliest childhood overweight prevention practices. The duration of breastfeeding seems to be inversely associated with risk of later development of overweight. Children should be taught to listen to their internal cues for hunger and satiety. They should not have to clean their plates if they are not hungry, and food shouldn't be used as a reward or withheld as a punishment because it promotes desire for highly palatable foods. The parent's domain includes what is served, where it is served, and when. The child's domain is choosing from among those foods how much and what to eat. The importance of parental role modeling of healthy eating and activity habits cannot be over-emphasized. ________________________________________________________________________
Topic: Nutrient Density Objective: Describe the concept of nutrient-density and explain its role in healthy eating patterns. Key Concept: Emphasizing nutrient-dense foods over energy-dense foods promotes healthy dietary habits. Nutrient-dense foods can provide critical nutrients without excessive energy intake; they also provide many other beneficial compounds. Nutrient-dense foods include fruit and vegetables, whole grains and lean meats. Energy-dense foods contribute a lot of calories to the diet and may or may not make significant contributions to micronutrient intake. They are often highly palatable and tend to promote overconsumption. Energy-dense foods include many baked goods, sweetened beverages, fried foods, and sweet or fatty snacks. To establish preferences for nutrient-dense foods, parents should provide a range of nutrient-dense foods from which children can choose and choose these foods for themselves. ________________________________________________________________________
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Topic: Activity Assessment Objective: Demonstrate methods to evaluate both physical activity and sedentary habits of children in a healthcare setting. Key Concept: To assess physical activity, ask about exercise, sports, play, and lifestyle in addition to sedentary habits. Physical activity can best be described using the acronym FITT: frequency, intensity, type, and time. Direct measures of physical activity include pedometers (are becoming common) and accelerometers (used mostly in research). Questionnaires may ask about outdoor playtime or sports participation. It is also important to assess sedentary time (TV, videos, computer games) as this represents a primary target for intervention and may be more important than physical activity per se. Children should get 60 minutes of physical activity daily; TV and videos should be limited to 2 hours or less per day. To guide you with physical activity interventions, it is useful to also ask about environmental or safety issues related to outdoor activity, the family's attitude and beliefs about exercise and sports participation, and motivation to change behavior patterns. ________________________________________________________________________ Topic: Activity Recommendations Objective: Give recommendations on how much physical activity children should get and nutritional guidelines for activity. Key Concept: Children and adolescents should get 60 minutes of physical activity daily; playtime and organized activities both contribute. Young children should have free playtime, but as children age, organized activity programs (such as sports) may help them meet physical activity guidelines. According to the Dietary Reference Intakes formulas, physical activity level can be classified as sedentary, low active, active, or very active. Physical activity makes a dramatic impact on total energy requirements. Active children and adolescents must be sure to meet their calorie needs for proper growth and development, and maintain adequate hydration. Preschoolers and school-aged children should drink 150 ml (5 oz) every 20 minutes during exercise; adolescents should drink 250 ml (9 oz) on the same schedule. ________________________________________________________________________
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Topic: Intervention Strategies Objective: Describe intervention strategies to prevent and treat the problem of childhood overweight. Key Concept: Physicians play a key role in preventing and treating overweight in children. Physicians are in the best position to identify potential weight problems in children. Routine measurements of height and weight and determination of BMI-for-age annually are the first steps. If a problem is identified, it must be communicated to the family in a sensitive manner so that there is no stigma attached, nor any blame placed. A medical assessment follows that includes a history and physical, family history, laboratory tests, nutrition and physical activity assessments, and psychological evaluation. Intervention includes setting appropriate goals which are based on age, BMI-for-age percentile, and the presence of co-morbidities. The key elements of a weight management program for children are: family involvement, behavior modification, dietary changes, and adjustments in physical activity to reduce sedentary time and increase active time. ________________________________________________________________________
Topic: Weight Management Objective: Describe effective strategies for weight management and how to incorporate these into an intervention plan. Key Concept: Weight management efforts should focus on changing family diet and physical activity behaviors. The primary goal is to help patients achieve and maintain a healthier weight. Behavioral goals need to be realistic, specific, and measurable. A stepwise approach is best - start with one or two small changes and build from there. Dietary strategies include making parents aware of their influence on children's intake and habits, encouraging breastfeeding to expectant moms, promoting increased fruit and vegetable intake, limiting sweetened beverages and juices, encouraging a range of healthy choices from which children can choose while avoiding excessive restrictions, and using behavior modification techniques such as a food diary to institute change. Physical activity strategies include limiting TV and videogame time, incorporating activity into daily life (taking the stairs), and finding activities that involve the whole family. ________________________________________________________________________
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Topic: Motivational Interviewing Objective: Describe the style, principles and common elements involved in motivational interviewing. Key Concept: Motivational interviewing is a patient-centered approach to effect behavior change. Motivational interviewing (MI) involves expressing empathy, helping the patient see the discrepancy between their own goals and behaviors, expecting resistance and ambivalence, and emphasizes both personal choice and responsibility on the part of the patient. It represents a shift from physician-directed traditional counseling where the physician provides advice and admonishment. In MI the relationship is more of a collaboration and partnership, with the physician eliciting the patient's motivations, goals, and ideas for behavior change. _______________________________________________________________________
Topic: Weight Loss Diets Objective: Describe characteristics of some weight loss diets and their appropriateness in the pediatric population.
Key Concept: Aggressive dietary intervention may be indicated in the presence of extreme weight and medical complications. In such situations, a protein-sparing modified fast may be appropriate as part of a comprehensive program at a pediatric obesity treatment center where close medical supervision is possible. No long-term benefit of such diets when compared to more moderate energy restriction has been found. While research is underway, there is not enough data on the safety and efficacy of low carbohydrate, low-glycemic index, or meal replacement diets in the pediatric population to recommend their use in general practice. ________________________________________________________________________
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Topic: Pharmacological Therapy Objective: Describe the current status of pharmacological treatments for pediatric obesity and any nutritional concerns. Key Concept: Pharmacological treatment of pediatric obesity is in its infancy; currently two medications are approved for use in adolescents. Research on pharmaceutical agents in the treatment of obesity in children is only just beginning. Two drugs are approved: Orlistat for adolescents age 12 and above, and Sibutramine for children 16 and older. Orlistat is a pancreatic lipase inhibitor; it reduces fat absorption by approximately 30%. Nutritional concerns relate to the potential for fatsoluble vitamin deficiencies. Sibutramine is an appetite suppressant that also stimulates thermogenesis. Long-term studies on both medications are needed in this population to determine any adverse outcomes on growth and health. Both medications result in modest improvements in weight status and BMI. ________________________________________________________________________
Topic: Surgical Intervention Objective: Describe the types of procedures, potential risks and benefits, and nutritional concerns related to bariatric surgery. Key Concept: Bariatric surgery is an aggressive approach to weight loss with potentially serious nutritional and health consequences. Bariatric surgery induces weight loss through malabsorption of nutrients or decreased intake as a result of smaller stomach size, or both. Restrictive type procedures, such as gastric banding, limit food intake only and do not interfere with digestion. Combined procedures, such as Roux-en-Y, or biliopancreatic diversion, utilize food restriction and malabsorption to produce weight loss; as such they have greater impact on nutritional status, as well as greater weight loss. The type and extent of nutritional deficiencies will depend on a number of factors including the amount of functional intestine, compliance with nutritional recommendations, etc. Bariatric surgery is not appropriate for children; it has been used in adolescents although long-term consequences on health and weight are uncertain. ________________________________________________________________________
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Bibliography
American Academy of Pediatrics. Prevention of pediatric overweight and obesity. Policy Statement. Committtee on Nutrition. Pediatrics 2003; 112: 424-430. Barlow E, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. Pediatrics 1998;102:1-11. Birch LL, Fisher JO, Davison KK. Learning to overeat: maternal use of restrictive feeding practices promotes girls' eating in the absence of hunger. Am J Clin Nutr 2003;78:215-20. Birch LL, Fisher JO. Development of eating behaviors among children and adolescents. Pediatrics 1998;101:539-549. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W., Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292(14):17241737. Durant N, Cox J. Current treatment approaches to overweight in adolescents. Curr Op Pediatr 2005;17:454-459. Epstein L, Valoski A, Vara L, et al, Effects of Decreasing Sedentary Behavior and Increasing Activity on Weight Change in Obese Children, Health Psychology 14(1995):109-115. Epstein L, Paluch R, Gordy C, and Dorn J, Decreasing Sedentary Behaviors on Treating Pediatric Obesity, Archives of Pediatrics and Adolescent Medicine 154(March 2000):220-226. Fisher JO, Birch LL. Restricting access to palatable foods affects children's behavioral response, food selection, and intake. Am J Clin Nutr 1999;69:1264-72. Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement Online 1991 Mar 25-17[cited 3/29/05];9(1):1-20. Gillman MW, Rifas-Shiman SL, Camargo CA Jr, et al. Risk of overweight among adolescents who were breastfed as infants. JAMA 2001;285:2461-2467. Hediger ML, Overpeck MD, Kuczmarski RJ, Ruan WJ. Association between infant breastfeeding and overweight in young children. JAMA 2001;285:2453-2460.
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Institute of Medicine. Preventing Childhood Obesity: Health in the Balance.Committee on Prevention of Obesity in Childhood and Youth, Food and Nutrition Board. Koplan JK, Liverman CT, Kraak VI, eds. National Academies Press, Washington, DC. 2005. Kirk S, Scott BJ, Daniels SR. Pediatric obesity epidemic: treatment options. J Am Diet Assoc 2005;105:S44-51. Krebs NF, Jacobson MS; American Academy of Pediatrics Committee on Nutrition. Policy Statement: Prevention of Pediatric Overweight and Obesity. Pediatrics 2003;112:424-430. Inge TH, Krebs NF, Garcia VF, Skelton JA, Guice KS, Strauss RS, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics 2004;114:217-223. Levin S, Lowry R, Brown DR, Dietz WH. Physical activity and body mass index among US adolescents. Archives of Pediatric and Adolescent Medicine 2003; 157:816-820. Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugarman HJ, Livingston EH, et al. Meta-analysis: Surgical treatment of obesity. Ann Intern Med 2005; 142:525-531. McDuffie JR, Yanovski JA. Treatment of childhood and adolescent obesity. The Endrocrinologist 2004;14:138-143. Mullen MC, Shield J. Childhood and Adolescent Overweight: The Health Professional's Guide to Identification, Treatment and Prevention. American Dietetic Association, 2004. O'Loughlin J, Gray-Donald K, Paradis G, Meshefedjian G. One- and two-year predictors of excess weight gain among elementary schoolchildren in multiethnic, low-income, inner city neighborhoods. American Journal of Epidemiology 2000; 152:739-746. Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA 1999; 282:1561-7. Sindelar HA, Abrantes A, Hart C, Lewander W, Spirito A. Motivational interviewing in pediatric practice. Curr Probl Pediatr Adolesc Health Cre 2004;34:322-339. Westenhoefer J. Establishing dietary habits during childhoood for long-term weight control. Ann Nutr Metab. 2002;46 Suppl 1:18-23. Zhaoping L, Maglione M, Wenli T, Mojica W, Aterburn D, Shugarman L, Hilton L, Suttorp M, Solomon V, Shekelle PG, Morton SC. Meta-Analysis: pharmacologic treatment of obesity. Ann Intern Med 2005;142:532-546.
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Readings
Bariatric Surgery: Alvarez-Leite J. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care 2004;7:569-575. Marcason W. What are the dietary guidelines following bariatric surgery? J Am Diet Assoc 2004;104:487-488. Scheier L. Bariatric surgery: life-threatening risk or life-saving procedure? J Am Diet Assoc 2004;1338-1340. Diet Assessment Tools: Dennison BA, Jenkins PL, Rockwell HL. Development and validation of an instrument to assess child dietary fat intake. Prev Med. 2000 Sep;31(3):214-24.
Influence of Media: The Henry J. Kaiser Family Foundation, Issue Brief: The Role of Media in Childhood Obesity, February 2004. Portion Size, Energy Intake and Weight: Orlet Fisher J, Rolls BJ, Birch LL. Children's bite size and intake of an entree are greater with large portions than with age-appropriate or self-selected portions. Am J Clin Nutr 2003;77:1164-70. Roe LS, Morris EL, Rolls BJ. Portion size of food affects energy intake in normal-weight and overweight adults. Obes Res 2001;9:75S. Kral TVE, Rolls BJ. Energy density and portion size: their independent and combined effects on energy intake. Physiology and Behavior 2004;82:131-138. McConahy KL, Smiciklas-Wright H, Birch LL, Mitchell DC, Picciano MF. Food portions are positively related to energy intake and body weight in early childhood. J Pediatr 2002;140:340-347. Nielsen SJ, Popkin BM. Patterns and trends in food portion sizes, 1977-1998. JAMA 2003 Jan 22-29;289(4):450-3. .
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Lifestyle Intervention: Epstein LH, Wing RR, Koeske R, Valoski A. A Comparison of Lifestyle Exercise, Aerobic Exercise, and Calisthenics on Weight Loss in Obese Children. Behavior Therapy 1985; 16:345-56. Suggestions For Parents: "We Can! Families Finding the Balance: a parent handbook," a publication of the National Heart,Lung, and Blood Institute as part of the National Institutes of Health and the US Dept of Health and Human Services, NIH Publication No. 05-5273, June 2005. 2003 American Dietetic Association publication "If Your Child is Overweight: A Guide for Parents, 2nd ed."
Electronic Resources:
Go to www.nal.usda.gov/fnic/foodcomp/ to search online for nutrient values of food in the USDA National Nutrient Database for Standard Reference, or to download the searchable database onto a Windows PC or a handheld PDA Dietary Guidelines for Americans 2005, Department of Health and Human Services(HHS) and the Department of Agriculture(USDA) http://www.health.gov/dietaryguidelines/dga2005/document/ Accessed January 26,2005 www.health.gov/dietaryguidelines www.MyPyramid.gov Rate Your Plate tool, contact Kim Gans (Kim_Gans@brown.edu) Healthy People 2010 national health objectives. http://www.healthypeople.gov/document/html/volume2/16MICH.htm#Toc494699668
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