presentation weight management children
TRANSCRIPT
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WEIGHT MANAGEMENT FOR OVERWEIGHT AND UNDERWEIGHT CHILDREN
Presented to
the Faculty of the Center for Graduate Studies
Adventist University of the PhilippinesProfessor: Miriam Razon-Estrada, RND, DrPH
In partial Fullfilment of the Requirements for the Course
PHSC 626 WEIGHT MANAGEMENT AND EATING DISORDERS
Submitted by
Thadee Katembo
May 11, 2010
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TABLE OF CONTENTS
Chapter Page
I. THE PROBLEM AND ITS BACKGROUND 3Introduction 3
The Problem 5Significance of the study 5
Scope and Limitations 6
Definition of the Key Terms 6
II. FACTORS AND CONSEQUENCES OF OVERWEIGHT AND
UNDERWEIGHT FOR CHILDREN
8
Factors and complications of overweight and obesity
Factors of Underweight among children
8
10
III.WEIGHT MANAGEMENT FOR CHILDREN
Assessment of Nutritional Status
Management or Intervention
11
11
14
CONCLUSION AND RECOMMENDATIONS 25
REFERENCES 26
Chapter I
THE PROBLEM AND ITS BACKGROUND
Introduction
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goal is to reduce by 50% the prevalence of being underweight among children younger than 5
years between 1990 and 2015. Childhood underweight is internationally recognized as an
important public health problem and its devastating effects on human performance, health, and
survival are well established (de Onis et al, 2004).
Worldwide, underweight prevalence was projected to decline from 26.5% in 1990 to
17.6% in 2015, and the number of underweight children was projected to decline from 163.8
millionin 1990 to 113.4 million in 2015. In developed countries, the prevalence was estimated
to decreasefrom 1.6% to 0.9%. In developing regions, the prevalence was forecastedto decline
from 30.2% to 19.3%. In Africa, the prevalence of
underweight was forecasted to increase from
24.0% to 26.8%. In Asia, the prevalence was estimated to decrease from 35.1% to 18.5% (de
Onis et al, 2004).
According to WHO, Globally, it is estimated that there are nearly 20 million children
who are severely acutely malnourished.2 Most of them live in south Asia and in sub-Saharan
Africa. Current estimates suggest that about 1 million children die every year from severe
acute malnutrition. (WHO, 2007)
According to UNICEF( 2009), worldwide, 14% are still born with a low birth
weight( less than 2500g), 25% of children under five years are underweight, 11% with wasting
and 28% present a stunting status. This situation is particularly alarming in South Asia with the
highest rate of 27% of low birth weight, 45% of underweight, 18% of wasting versus 38% of
stunting. ( The State of the World's Children 2009)
These data reveal that the situation is still far to be improved, whereas we are in the year
2010, ten years from the millennium development objectives were set.
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According to de Onis (2004), about 53% of all deaths in young children are attributable to
underweight, varying from 45% for deaths due to measles to 61% for deaths due to diarrhea.
For the particular case of the Philippines (UNICEF, 2009), low birth weight is 20%. Among
under-five children, 28% are underweight with 6% of wasting versus 30% of stunting.
The Problem
This paper aims to present principles and strategies to be used in weight management for
children.
Specifically, it will answer the following:
1. What are the main factors and consequences of overweight and underweight among
children?
2. What are the efficient strategies of weight management for children in terms of
prevention and treatment?
Significant of the Study
Weight management for children is a very important topic for parents and health
professionals.
1. For parents. To understand factors and consequences is a key to be involved in actions
for the wellness of their children
2. For health professionals. The best prevention of weight management problems starts in
the early childhood.
Scope and Limitations
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The concept of children being wide ( up to 18 years), this presentation has a special
emphasis to children under five years in the following aspects:
Factors and consequences of overweight and underweight.
Strategies of weight management for children in terms of prevention and treatment.
Definition of Key Terms
1. Child. The United Nations Convention on the Rights of the Child defines a child as "a
human being below the age of 18 years. In this paper, the focus is on the under-five years
old.
2. Weight management. It pertains to keep the body weight at a healthy level. It implies
weight loss for obese and overweight, weight maintenance of optimal weight and weight
gain for underweight peoples.
3. Underweight. From age 2 to 20 years , it refers to a BMI that is less than the 5th
percentile.
4. Underweight. For children aged 059 months, using the standard of NCHS/WHO,
moderate underweight is the index weight/age below minus two standard deviations
from median weight for age and severe underweight is the index weight/age below
minus three standard deviations from median weight for age of the NCHS/WHO
reference population.
5. Overweight. From age 2 to 20 years, it refers to a BMI between the 85th and 95th
percentile or weight higher than 120 % of ideal (50th percentile) for height.
6. Obesity . For age 2 to 20, it refers to a BMI equal to or greater than the 95th percentile
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7. Wasting. For children aged 059 months, using the standard of NCHS/WHO, it refers to
the index weight/height below minus two standard deviations from median weight for
height of the NCHS/WHO reference population.
8. Percentile. The set of numbers from 0 to 100 that divide a distribution into 100 parts of
equal area, or divide a set of ranked data into 100 class intervals with each interval
containing 1/100 of the observations. A particular percentile, say the 5th percentile, is a
cut point with 5 percent of the observations below it and the remaining 95% of the
observations above it.
9. Stunting. For children aged 059 months, using the standard of NCHS/WHO, it refers to
the index height/age below minus two standard deviations from median height for age of
the NCHS/WHO reference.
10. Pluricarential syndrome. It refers to a nutritional condition resulting from a reduced
intake or reduced absorption of several nutrients.
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Chapter II
FACTORS AND CONSEQUENCES OF OVERWEIGHT AND UNDERWEIGHT
FOR CHILDREN
The present chapter describe briefly the main contributing factors to the double burden of
malnutrition ( overweight and underweight) among children.
2.1 Factors and complications of Overweight / Obesity among Children
Factors
To understand strategies of intervention, it is a sine qua non condition to identify the
main contributing factors to overweight and obesity among children and teenagers.
Several factors have been listed according to different studies. Below is a summary of them.
1. Having overweight parents, which gave their children a 48 percent chance of becoming
overweight too (Iannelli, 2004).
2. Feedings practices. Parental feeding practices can influence the development of
childrens and adolescents food preferences. Infants have an innate preference for sweet
and salty flavours whereas bitter and sour preferences are acquired. Children consume
what is familiar to them and available to them in the feeding environment.
3. Excessive juice and sweetened beverage consumption. The odds ratio of becoming obese
among children increased 1.6 times for each additional can or glass of sugar-sweetened
drink that they consumed every day. The introduction of juice in the diet of infants
younger than six months is an other aspect of this factor.
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4. Parental restriction of childhood eating. Parents who overly control or restrict their
childs intake in an effort to prevent obesity can produce negative and unintended effects
on childrensfood intake, preferences and satiety. In families with a history of obesity,
research has suggested that parents who have problems regulating their own eating
behavior tend to try to control their childs eating behavior more than families without
obesity and as a result, the child demonstrates a lack of self-regulation.
5. Speed of eating. In several studies from infancy through childhood, overweight infants,
toddlers and children have been shown to eat fast and fail to slow down at the end of a
meal compared to leaner children.
6. Lack of physical activity. In his study on television viewing patterns of boys and girls
ages 8-16 years, Andresen et al found that approximately 50% spent 2-3 hours per day
watching television. Those who watched four and more hours of television daily had the
highest skinfold thickness and BMI than those who watched the least amount of less than
1 hour. (Copperman & Jacobson, 2004).
Complications
There are several complications according to the degree of obesity of the child. The most
frequent are: type 2 diabetes, hypertension, snoring with episodes of apnea or coughing fit and
day time somnolence, orthopaedic complications, hyperlipidemia, gallstones, asthma, insulin
resistance, psychosocial consequences such as school performance, social adjustment, signs of
depression, concerns about weight, eating disorders ( Estrada, 2004).
2.2 . Factors of Underweight among children
Without being exhaustive, the following can be considered among the main factors of
underweight among children.
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1. Low birth-weight (
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3.1 Assessment of Nutritional Status
It has been clear that the first step in the treatment process is to access the childs and
familys nutrition, physical activity, living environment, and psychosocial status.
1. Nutrition Assessment
This step will apply the ABCD of nutrition assessment: anthropometric measurements,
biochemical assessment of blood and urines, clinical general examination, and dietary
assessment. But the focus is here on the anthropometric and dietary assessments.
Anthropometric Measurements
a. BMI System (Children of age 2 to 20 years)
For children, anthropometry will concern the weight and Height to computer the BMI. It
is calculated the same way as for adults. After BMI is calculated for children and teens, the BMI
number is plotted on the CDC BMI-for-age growth charts (for either girls or boys) to obtain a
percentile ranking. The percentile indicates the relative position of the child's BMI number
among children of the same sex and age. The growth charts show the weight status categories
used with children and teens (underweight, healthy weight, overweight, and obese).
(CDC, 2009).
Table 1: Weight Status Categories for the Calculated BMI-for-age Percentile
Weight Status Category Percentile Range of BMI
Underweight Less than the 5th percentile (
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The WHO Global Database on Child Growth and Malnutrition uses a Z-score cut-off
point of
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(school lunch and restaurant dining), prepared foods brought into the house and family food
preparation techniques. (Copperman & Jacobson, 2004).
The same process should be followed, in case of undernutrition to identify the different
factors related to the child and/or to the family for a sustainable intervention.
2. Physical Activity Assessment
An assessment the childs physical activity level should be performed to identify barriers
to increasing both scheduled exercise and habitual physical activity. Careful interviewing
regarding time spend performing sedentary activities such as television viewing, computer use
and electronic game use can reveal excessive periods of inactivity. Discussing the childs
exercise preferences can aid in the formulation of activity goals. (Copperman & Jacobson, 2004).
3. Environmental Assessment
Environment can affect the lifestyle choices made by the patient and family and therefore
must be assessed as part of a comprehensive evaluation. Factors to be assessed are such as family
composition, family income, family schedules, childcare arrangements, food availability, school
environments, community environments with playgrounds, etc. (Copperman & Jacobson, 2004).
4. Psychosocial Assessment or Behavior Modification
An assessment of the childs/ adolescents and parents readiness to make lifestyle
changes is an important measure of whether the weight management program will be successful.
3.2. Management or Intervention
3.2.1. Management of overweight and obesity
Necessity of Prevention since Childhood and Adolescence
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Although it is well-documented that it is possible to reduce obesity modifying energy intake and
expenditure, treatment of manifest obesity in both adults and children has been disappointing , with very
few programs showing lasting weight reduction. (Bergstrom and Hernell, 2005)
Why is it important to fight overweight since the childhood? The origin of adult obesity and its
adverse health consequences often begins in childhood. Adipocytes number increases rapidly during the
first year of life to reach three times the number at birth. Percentage body fat increases from 16% at birth
to about 25% over the first year. By age 6, body fat decreases to 14 % of body mass for girls and 11% for
boys. Thereafter, percentage fat progressively increases to average 16% at age 11 years in boys and 27%
in girls. Children who gain more weight than peers tend to become overweight adults with increased risk
for hypertension, elevated insulin, hypercholesterolemia and heart disease. ( McArdle, Katch and Katch,
2007)
Although it may be easier to treat obesity in children than adults, it is obvious that the best
strategy is primary prevention targeting all children. However as obesity can be regarded as an epidemic
caused by modern lifestyle, effective preventive measures must not focus only on individual behaviour
but also on the social and physical environment for children, supporting more daily physical activities.
(Bergstrom and Hernell, 2005)
Interventions approaches
Once the child or adolescent has been identified as at risk for overweight or overweight,
assessed for lifestyle risk factors and received a medical evaluation, the an intervention with
weight goals can be developed with the child and family.
Table 3 : Recommendations for weight goals for children and adolescents
Ageyears
BMI85th-94th %ile)
BMI95th %ile
Absence of medicalcomplications
Presence of medicalcomplication
2-7 X Weight maintenance Weight maintenance
2-7 X Weight maintenance Weight loss
>7 X Weight maintenance Weight loss*
>7 X Weight loss* Weight loss*
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*Children and adolescents in this group should be encouraged to reduce their weight by 1 pound (0.45kg)
per month to eventually achieve a BMI less than the 85th percentile.
Medical complications include mild hypertension, dyslipidemias, insulin resistance, sleep apnea, genu
varum, and cutaneous candidiasis.
Treating pediatric overweight with a family-centered multidisciplinary approach
addressing nutritional, physical activity, and psychosocial issues offers the best chance at
achieving lifestyle changes and weight goals.
1- Parental Support and Behavioral Modification
Parental involvement is an integral component of pediatric weight management. When
the child/teenager and his or her parents or caretakers are ready to make lifestyle modifications,
the family can learn to support the child utilizing two different strategies: the cognitive
behavioral and the motivational interviewing.
a- Cognitive behavioral strategies
This is a theory of learning for behavioral change that describle learning as a
reciprocal relationship between behavioral, environmental and personal factors.
The key components of this approach include nutrition education on lifestyle
behaviours and their relation to chronic diseases, modification of the home/school choices, self
monitoring, family commitment to long-term and frequent follow-up.
b- Motivational interviewing
Traditionally used in substance abuse counselling, this approach is being considered
now as a potentially effective adjunct to weight management interventions. It addressesn the
ambivalence of wanting to modify lifestyle behaviours that many patients and their families
express to practitioners. Through this patient-centered approach, the patients identify
discrepancies between their current behaviour and desired goals, acknowledging ambivalence
rather than ignoring it. Utilizing an emphatic interactive listening style to increase the patients
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and families motivations, the practitioner actively elicits the patients articulation of behavior
change.
2- Diet therapy intervention
Here are several different dietary approaches to help change childrens, adolescents and
families eating patterns.
A. General Principles for Age appropriate interventions
Children and adolescents at risk for obesity, whose goal is weight maintenance, should
be followed monthly by a registered dietitian and/or a paediatrician. Thosewho have a BMI
95
th
percentile should be monitored at least every 2 weeks during the weight loss phase and
monthly during weight maintenance.
Infants :
- Promote breastfeeding
- Counsel to avoid juice prior to 6 months of age
- Encourage water as a between feeding beverage
- Adequate transition from exclusive breastfeeding to family foods, referred to as
complementary feeding, from 6 to 18-24 months of age ( whole grains flour )
- Increase water, fruits and vegetables progressively
- Decrease sweetened beverage, juice, refined carbohydrate and saturated fat
consumption
- Advice slow down when eating
- Controlling feeding practices by the mother
School-age child and adolescent:
- Healthy snack suggestions
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- slow down when eating ( wait 30 min before 2nd portions)
- Increase water intake
- Decrease TV viewing
- Family activity suggestions
B. Nutritional Guidelines
The Food Guide pyramid
- Increasing fruit, vegetable and whole grain consumption ( brown rice, wheat bread) while
decreasing sweetened beverage, juice, refined carbohydrate and saturated fat
consumption will improve the nutritional quality of the diet and reduce excessive caloric
intake.
- The American Academy of Pediatrics recommends adolescents limit their juice intake to
two 6 fl oz servings per day or half the recommended fruit servings each day
Traffic Light or stoplight Diet
For preschool and preadolescent children, Epstein et al (1990) have been used the
stoplight diet which is a plan of 900-1300 kcal per day.
Low gylcemic index, low fat diet
Theglycemic index of a food (GI) is the glycemic response after the consumption of a
specific food . In other words, it is a measure of the effects of carbohydrates on blood sugar
levels. To be more explicit, the glycemic index (GI) rates carbohydrate foods on how quickly
blood sugar / glucose levels increase in the 2 - 3 hours after eating as the carbs are converted into
glucose. (http://optimalhealth.cia.com.au/gi17.html)
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At Schneider Childrens Hospital Center for Atherosclerosis Prevention, the meal plan
limits refined carbohydrate consumption with specific macronutrient goals of 50% carbohydrate,
20% protein and 30% fat. It encourage the consumption of lean meats, fish and poultry, low-fat
dairy products, monounstaturated oils, whole grains and fresh fruits and vegetables (Copperman
& Jacobson, 2004).
Table 4: Glycemic Index of foods
Low Glycemic Index Foods
(Score under 50)
Moderate Glycemic Index foods
(Score 50-70)
High Glycemic Index foods
(Score >70)
Barley
GrapefruitKidney beans, lentils
Apple, pear, peach
Orange, grape
Non fat plain yogurtLow fat milk
Sweet potato
Whole wheat breadCorn, popcorn
Brown rice, couscous
Whole wheat pita
Green pea soupApricot, mango
Whole grain pasta
White bread
Rice cakesFrench fries
Cornflackes
Baked white potato
Instant white riceCandy, regular soda
(Copperman & Jacobson, 2004).
Protein sparing Modified Fast (PSMF)
- The diet consists of caloric restriction between 600-900 caloriesper day, 1.5 to 2.5 grams
of high biological value protein per kilogram of weight per day and extremely limited
carbohydrate and fat intakes.
- A minimum daily consumption of 1.5 liters of water is recommended. It requires
supplementation of vitamins and minerals to maintain nutrient adequacy ad close
monitoring of serum electrolytes.
- This diet requires medical supervision by multidisciplinary team.
Very Low carbohydrate, High-fat Ketogenic Diet
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The use of Very Low carbohydrate, High-fat Ketogenic Diet that induces ketosis
(overproduction of ketones) to promote weight loss has a distinct advantages in shor-term
treatment of overweight adolescents.
The ketogenic diet is a special high-fat, low-carbohydrate diet. The name ketogenic means that it
produces ketones in the body (keto = ketone, genic = producing). Ketones are formed when the body uses
fat for its source of energy. Usually the body usually uses carbohydrates (such as sugar, bread, pasta) for
its fuel, but because the ketogenic diet is very low in carbohydrates, fats become the primary fuel instead
The same diet helps also to control seizures in some people with epilepsy.(Schachter, 2008)
From a 12-week randomized, controlled adolescent weight reduction study of
40subjects(Sondike et al, 2003), the ketogenic consisted of 20 grams of carbohydrate and ad-lib
intake of protein,fat and energy for the intial 2 weeks. For weeks 3-12, carbohydrate intake was
increased to 40 grams daily by promoting nut, fruit and whole grain consumption and
consumption of fluid intake of 60 oz per day ( 1 ounce =29.57 ml). Electrolyte imbalance and
micronutrient deficiencies were averted bu addition to meals of an iodized salt containing a
misture of sodium cholird, potassium cholird,a nd a multivitamin supplement daily. (Copperman
& Jacobson, 2004).
3- Physical activity
Incorporating physical activities (such as using the steps instead of an elevator or walking
more and driving less) into daily routines can improve weight management outecomes.
- Decreasing sedentary activity by limiting television viewing has shown improvement in
BMI in children. The American Academy of Pediatrics recommends limiting television
viewing to 1-2 hours per day.
- Parents need to promote and model increased physical activity and decrease sedentary
activities for the family. Strongly encouraging children to play outside after school for 30
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the United Nations System Standing Committee on Nutrition and the United Nations Childrens
Fund have come up with a joint statement on a new strategy named Community-based
management of severe acute malnutrition. Uncomplicated forms of severe acute
malnutrition should be treated in the community (WHO, 2007).
Here is the Guideline as followed in the Democratic Republic of Congo.
Phase 1 - Recovering normal metabolic function and rehydration.
Patients without an adequate appetite and/or a major medical complication are initially admitted
to a hospital for Phase 1 treatment.
- During this phase patients are given a therapeutic milk formula called F-75(meaning 75
kcal/100ml of solution ) and energy intake is 100 kcal/Kg/day.
- ReSoMal(oral rehydration salts solution for severely
malnourished children).
Table 5. Recipe for ReSoMal oral rehydration solution
Ingredient Amount
Water (boiled & cooled) 2 litresWHO-ORS * 1 litre-packet
Sugar 50 g
Electrolyte/mineral solution 40 ml
- Medical treatment of complications
Transition Phase ( if necessary).
During this phase the patients start to gain weight slowly as a fortified milk formula
called F-100 or a Ready-to-Use Therapeutic Food (RUTF) is introduced.
Phase 2 - Gaining weight with the right kind of therapeutic food. (Community level)
This phase receives patients from the phase 1 and when there is no any complication, the
treatment start by this phase, the Community-based management of severe acute malnutrition.
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The central principle of this approach is to detect severe acute malnutrition before the
life-threatening symptoms and treat malnourished children in their homes, rather than having
them travel for miles for help.
The principle of treatment is the use of the Ready-to-Use Therapeutic Food (RUTF). No
use of milk like the formula F-100 because it needs to be prepared by trained personnel and
presents a risk of contamination due to its high water content.
We have three main RUTF used:
Plumpy Nut
Ingredients : Plumpy Nut is composed of peanut butter, vegetable fat, dry skimmed milk,
lactoserum, maltodextrines, sugar, mineral and vitamin complex.
Table 6. Nutritional value of Plumpy Nut
Energy 545 Kcal/100gr. One sachet (92gr) is 500 Kcal; 10% of protidics calories /
59% of lipidics calories.
Vitamins: vit A (910mcg), vit D (16mcg), vit E (20mg), vit C (53mg), vit B1
(0.6mg), vit B2 (1.8mg), vit B6 (0.6mg), vit B12 (1.8mcg), vit K
(21mcg), biotine (65mcg), folic acid (210mcg),pantothenic acid
(3.1mg),niacin (5.3mg).
Minerals Calcium (320mg), Phosphorus (394mg), Potassium (1111mg), Magnesium(92mg), Zinc (14mg), Copper (1.78mg), Iron (11.53mg), Iodine (110mcg),
Sodium (189mg), Selenium (30mcg).
- How to use it ?
Child of height >85cm: 5 sachets /day ( that is 2500 Kcal)
Child of height
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Minerals, Milk calcium, Amino acids, Vitamins.
Table 7. Contains only vegetable ingredients with the exception of the milk constituents.
Weight % Energy %
Protein 14,5 % 11 %
Fat 31,0 % 53 %Carbohydrate 47,5 % 36
- How to use it?
BP100 (529.4 Kcal/100gr) and One bar of BP-100 (56.7gr) is 300 Kcal.
Child of height >85cm: 9 bars /day ( 2700 Kcal)
Child of height 40 8(4000Kcal) 56
(Compact for life, http://www.compactforlife.com)
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CONCLUSION AND RECOMMENDATIONS
To present the main factors and consequences of overweight and underweight among
children and the efficient strategies of weight management for children in terms of prevention
and treatment, these were the objectives of this presentation.
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Considering the double burden linked of overweight and underweight among children,
their weight management needs a particular attention for both parents and health professional as
consequences are numerous in their future life.
Factors of overweight are more related to the diet intake, the lack of exercise, all coupled
to a need of behaviour modification. The key of success is prevention for both two aspect of
weight problems. However, when overweight and obesity is already presented, the three major
actions are the behaviour modification by health and nutrition education, the diet therapy and the
physical therapy.
Regarding the developing countries, it is not yet the time to ignore the problem
underweight due to malnutrition among children with the underlying factor of malnutrition
during the pregnancy and the high prevalence of low birth weight. Interventions should consider
those factors for prevention while taking care of those who are already sick. The current strategy
to involve also parents in the community-base management of acute malnutrition would help to
lead them for more responsibility. Above all, there is a need of political engagement in the
resolution of malnutrition in developing countries.
REFERENCES
Alasfoor,D, Traissac,P., Gartner, A. & Delpeuch,F .(2007) Determinants of persistentunderweight among children, aged 6-35 months, after huge economic development and
improvements in health services in Oman. Journal of Health Population and Nutrition,
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Schachter, S.C.(2008).Ketogenic Diet. Retrieved on May 9, 2010 fromhttp://www.epilepsy.com/epilepsy/treatment_ketogenic_diet.
UN (1989).Convention on the Rights of the Child The Policy Press, Office of the UnitedNations High Commissioner for Human Rights) Retrieved on May 2, 2010 from
http://www.hakani.org/en/convention/Convention_Rights_Child.pdf
UNICEF. The State of the World's Children 2009
WHO, WFP, UNICEF & UNSSCN (2007). Community-based management
of severe acute malnutrition.Retrieved on May 2, 201o from
http://www.who.int/nutrition/topics/Statement_community_based_man_sev_acute_mal_eng.pdf
WHO (2006), Overweight and Obesity, Fact sheet N0 311. Media centre:
http://www.who.int/mediacentre/factsheets/fs311/en/index.html, Accessed July 15, 2009
In the context of malnutrition by nutrient deficiency.
Voir PCCMA of OMS
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Conclusion
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population.
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The State of the World's Children 2009, Maternal and newborn health crisis
http://www.unicef.org/sowc09/statistics/tables.php
http://www.unicef.org/sowc09/statistics/tables.phphttp://www.unicef.org/sowc09/statistics/tables.php -
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http://www.sarpn.org.za/documents/d0001945/Nutrition-strategy_WorldBank_5.pdf
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Traitement de la malnutrition aigu svre
http://www.compactforlife.fr/traitement-de-la-malnutrition/
http://www.compactforlife.fr/traitement-de-la-malnutrition/http://www.compactforlife.fr/traitement-de-la-malnutrition/http://www.compactforlife.fr/traitement-de-la-malnutrition/http://www.compactforlife.fr/traitement-de-la-malnutrition/ -
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