24/06/2016

1

Weight Management for Children and Teenagers

Niamh Kelly

Christina Meade

#PracticalPaediatrics

Learning Outcomes

Initial assessment: what to include

Follow up

Practical advice and support for the family

Case study

©Practical Paediatrics

24/06/2016

2

Raising the Issue with Children

<5 years old too young to explicitly talk about body weight

Assess the maturity of your patient

Becoming aware of weight is a normal part of growing up

It is an opportunity for someone to listen to their concerns

Parent and child wants to know you are

on their side

©Practical Paediatrics

24/06/2016

3

Initial Assessment

1hr minimum

Treatment aims should be realistic-

Pre-puberty children aim should be to maintain weight while they grow

In pubertal children some weight loss will be needed

©Practical Paediatrics

Assessment: Anthropometry

As discussed in session 1

Height, weight and waist measurement

May be appropriate to offer parents to get their measurements also taken

©Practical Paediatrics

24/06/2016

4

BMI and Waist Charts

If weight is over 120kg can be difficult to plot on Centile charts.

©Practical Paediatrics

Poll Question 1

Do you encourage parents to monitor weight on the scales at home?

Yes

No

©Practical Paediatrics

24/06/2016

5

Fear of Eating Disorder

Serious and complex condition

Not primarily about food

Unhealthy way of coping with emotional distress

No evidence that discussing weight as a matter for health in a positive caring way promotes eating disorders

If concerned refer to GP/ CAMHS

©Practical Paediatrics

Assessment Form: What to Include

Reason for referred/ Who?

Past medical history

Relevant medical family history

Medication

• Anti Depressants

• Anti Psychotics

• Corticosteroids

• Anti-Convulsants

24/06/2016

6

Assessment Form: What to Include

Emotional wellbeing

Sleeping habits

• 11+ hrs for under 5 year olds

• 10+ hrs for over 5 year olds

• 9+ hrs for over 10 year olds

• Screens off an hour before bed

• Bedrooms should be a tech free zone

Physical activity: PE, clubs, walking to school?

• Under 6s need more than 3hrs of activity each day

• Children need more than 60 minutes of moderate to vigorous activity per day.

Need referral to physio?

Need to Consider:

Transport Mode

Wii fit

Safe place to play

Scooter/ bike/ flicker

Local Activities

Pedometer/ Apps/ Fitbit

Who can help become more active?

24/06/2016

7

Two thirds of Irish 9 year olds spend 3 hours per weekday on TV alone (Williams et al, 2009)

If parents watch 2+ hours per day, children are 5 times more likely to do the same (Jago, 2013)

Children who spend more than 3 hours on screen-time tend to have more behavioural problems; more hyperactivity; more difficulty getting on with other children and making friends

Health Implications for Screen‐time

A) decreasing active time

B) increasing mindless eating

C) disturbing sleep patterns

Research shows increase in screen time leads to increase in OBESITY, BLOOD PRESSURE, DEPRESSION, ANXIETY and ATTENTION DISORDERS.

Screen time increases obesity by:

24/06/2016

8

Mealtime

Shopping / Cooking

Meal pattern

Who is present

Screens Clean Plate

Policy/

Seconds

Access

School Meals

Food Cravings

Assessment

Prior to the Assessment

• Send out a 3 day food diary (+ guidelines for filling out the diary, 2 weekdays + 1 weekend, portion sizes and as much detail as possible)

During Assessment

• Diet History: include a list common food prompts e.g. how often do you eat pizza, drink coke, etc

24/06/2016

9

Poll Question 2 & 3

How do you assess your patient’s dietary intake?A. Food Diary

B. 24 hours food recall

C. Food Frequency Questionnaire

Do you enter your information into nutritional software to analyse?

Yes

No

24/06/2016

10

Nutritional Priorities

Identify sources of high calorie foods

Iron content, especially teenage girls

Calcium content

Micronutrients: +/- multivitamin required?

Setting Goals

Prompt child and/ or parent to try to identify main problem areas

Encourage appropriate goals

Contract

Encourage questions from the parent/child, summarize a plan, and discuss a follow up

Child and parent should leave feeling positive and supported

24/06/2016

11

Meal Plan

Breakfast     

        

   

Lunch    

      

  

 

Dinner    

      

  

 

Snack Options

       

Drink Options

       

 

  Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday 

Breakfast   2 x Weetabix with low fat milk 1 x banana   water 

1  bowl of Porridge with frozen berries    water 

1 bowl branflakes/ shreddies / high fibre cereal 1 glass of juice  water

1 bowl Ready brek with tinned fruit (natural juice e.g peach/pear)  water

1 bowl of cereal of choice  with fruit   water

2 slices of wholemeal toast with peanut butter/ 2 rashers 1x fruit water

2 slices of wholemeal toast with 2 egg omelette or scrambled egg water

snack  Fruit ( fresh, frozen, tinned in juice) 

fruit  fruit  fruit  fruit  fruit  fruit 

Lunch  2 x Wholemeal bread leftover meat from Sunday dinner and tomato    Water 

1 x wholemeal Pitta bread with ham and lettuce     Water  

1 x wholemeal Roll with low fat cheese and cucumber     water 

Wholemeal Tortilla wrap with Chicken/ turkey and peppers     water 

2 x Wholemeal bread with tuna and sweet corn     water  

Stir fry noodles  with pork with sweet corn/ mushrooms and peas   water  

Roast chicken/ beef/pork/lamb with  2 x vegetables and 2 x potatoes or scoops of mashed potato water 

snack  Homemade soup  with small roll  water 

3 x crackers with low fat cheese  Sugar free squash 

3 rice cakes with peanut butter or cheese spread water 

1 slice of malt loaf/ banana bread  Glass Low fat milk 

1 packet of popcorn  Glass Low fat milk  

Low fat yogurt   Sugar free squash  

Sugar free jelly   water 

Dinner  Chicken curry (include frozen and fresh vegetables) and boiled rice      Glass Low fat milk  

Fresh  white fish and vegetables (peppers, onions, tomatoes etc)  oven baked with 1 x baked  potato and low fat coleslaw  water 

Shepherd’s pie with broccoli and carrots        Glass Low fat milk 

Pasta and pesto with added vegetables and bacon      water 

Grilled fish in breadcrumbs with baked beans and oven chips      Sugar free squash 

Chicken  fajita with tomatoes, peppers/ onions, low fat sour cream      water 

Baked beans / tinned sardines on 2 x  toast or tuna with pasta salad     water 

Before bed (ONLY IF HUNGRY) 

Low fat yogurt  low fat rice pudding 

Sugar free jelly  Low calorie hot  chocolate 

Low fat custard  1 mini pizza  Low fat yogurt 

 

Meal Plan

24/06/2016

12

Follow Up

Ideally within one month

Highlight goals set in initial session & ask for feedback

Re-measure anthropometry

Food diary or diet history

Concentrate on area of specific nutrition education

• How to read food labels

• Portion sizes

• Fat and sugar content of food

• Shopping

Individual or Group Therapy?

Need to have minimum 10 patients to invite to group programme

Can be time consuming designing programme but if effectively run can save time in long run

Group dynamics can work well, good support network

May be appropriate to run some group education sessions e.g. shopping trip/ food labels

24/06/2016

13

Video Clip

24/06/2016

14

Practical Tips

Written information – use existing resources for parents

• SafeFood

• Apps: carbs and cals

• My fitness pal

• Safefood app

• Pedomoter

• Clear drinking cup- measure out portions

Practical Tips

24/06/2016

15

Red Flags

Poor correlation between reported dietary intake and overall progress

Short stature

Intellectual Disability

Dysmorphic features

Snoring

Low mood

Case Study: 15 year old boy

24/06/2016

16

Anthropometry: Unable to plot on BMI chart

Date Referral21/9/15

Initial Assessment15/2/16

Weight  145kg 154kg

Height 181cm 181cm

BMI 44.3kg/m2 47kg/m2

Background

Family History

• High cholesterol

• Diabetes- father type 2

• Obesity

Birth History

• Born 41/40

• Birth weight 3.8kg

• No early feeding issues

Social History

• At home with Mum

• Only child

• Sees dad every second weekend

Previously attended CAMHS

One off appointment with Dietitian

24/06/2016

17

Lifestyle

Dropped out of school last year

Refused to engage in home-schooling

Physical activity

• No planned activities

• Walks to take-away/ shop

• Used to walk around park, stopped 2/3 months ago

Sleep pattern 2am-10am

Screen Time

• Daily screen time ~ 10-12 hours at home (TV, iPad and ‘Gaming’)

Diet History

Breakfast (at home) None

Mid morning (Mum gone to work): Egg McMuffin/ burger & large fries, large fizzy drink

Lunch Soup & white bread roll with butter

Mid afternoon Chocolate +/- Biscuits, up to 1 packet

Dinner (at home) Pasta with mum occasionally/ /Ready meal

Pizza take away/ McDonalds meals/

Before bed Biscuits/ Sausage sandwich/ waffles/ Toasted

sandwich

1L coke throughout day

24/06/2016

18

Agreed Goals

Start having breakfast daily

Have evening meal with Mum on weekdays

Go out to meet with cousins on ‘green’ in evenings

Also at Initial AssessmentReviewed by Consultant and bloods taken: Insulin, Glucose, Thyroid function, LFTs and Vitamin D

Referral made to Physio and Psychology

Date Referral21/9/16

Initial Assessment15/2/16

Cancelled1/3/16

Review 7/3/16

11/4/16 16/5/16

Weight  145kg 154kg 157kg 153.3kg 151.2kg

Height 181cm 181cm 181cm 181cm 181.5cm

BMI 44.3kg/m2 47kg/m2 48kg/m2 46.8kg/m2 45.6kg/m2

Cancelled as did not want to attend as felt he had put weight on 

Gave Prescriptive Meal plan

Sticking to meal plan, made adjustments

Started working on behaviour change, eating habits

24/06/2016

19

Update

Dietary habits much improved. Only having one takeaway per week. Still struggles with snack food in house.

Commenced on Metformin for high insulin

Started to engage with Psychology (3 sessions to date)

Aiming to go back to school in September

Having monthly review with Dietitian, commencing education on portion sizes, food labels etc.

Useful Resources

Safefood Bring Back Play: http://www.safefood.eu/Childhood-Obesity/Your-Tools/Bring-Back-Play.aspx

Weight Management: Lifestyle services for overweight or obese children and young people: https://www.nice.org.uk/guidance/ph47

Irish Heart Foundation Shopping Card: http://www.irishheart.ie/iopen24/food-shopping-card-t-7_21_1249_1257.html

Royal College of Physicians Obesity Document: https://www.rcpi.ie/news/publications/topic/obesity/

24/06/2016

20

Useful Resources

Safe Food Childhood Obesity http://www.safefood.eu/Childhood-Obesity/Welcome.aspx

Health Promotion: https://www.healthpromotion.ie/

Anthropometry Video Clips http://www.hse.ie/eng/health/child/growthmonitoring

Communication and Language http://www.hse.ie/eng/health/child/healthyeating/healthprofessionals/healthprofs.pdf

Questions & Answers

24/06/2016

21

Thank you for joining today’s Practical Paediatrics Webinar

A survey will follow shortly: please share your feedback

#PracticalPaediatrics

Coming in Autumn 2016

Details soon on www.abbottnutrition.ie