1. Childhood Obesity: More Than Just BMI
Presented by: Erica Timmermann
Dietetic Intern 2009
NTR 622
Case Study Seminar
Julie Moreschi
Spring 2009

2. Childhood Obesity
Obesity among children and adolescents is on the rise today and is a major health concern.
According to the NHANES survey from and showed that obesity has increased by:
5.0 % to 12.4 % among children aged 2 to 5 years of age.
And a 6.5 % to 17 % increase among children aged 6 to 11 years old.
[1] Centers for Disease Control and Prevention. Overweight prevalence. Available at website: Assessed April 3rd 2009, 2009.

3. Illinois and Chicago Childhood Obesity Rates
In 2007 the state percentage of children obese in Illinois was 12.9% of children, while 15.7% of children were considered overweight in Illinois.
Rates among children living in the Chicago area in 2007 was 15.9% of children were obese, while 18.7% were considered overweight.
[2] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results Illinois 2007 dietary behaviors percentage of students who were obese. Available at website: Assessed April 3rd 2009, 2009.
[3] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results Illinois 2007 dietary behaviors percentage of students who were overweight. Available at website: Assessed April 3rd 2009, 2009.
[4] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results chicago, il 2007 percentages of student who were obese. Available at website: Assessed April 3rd 2009, 2009.
[5] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results chicago, il 2007 percentages of students who were overweight. Available at website: Assessed April 3rd 2009, 2009.

4. Childhood obesity is defined for children and adolescents aged 2 through 19 years of age as:
Overweight being defined as a BMI at or above the 85th percentile and lower than the 95th percentile.
Obesity being defined as a BMI at or above the 95th percentile for children of the same age and sex.
[6] Centers for Disease Control and Prevention. Defining childhood overweight and obesity. Available at website: Accessed April 5th 2009

5. Pathophysiology of Childhood Obesity
Excess fat accumulates in children and adolescents when there is an increase in energy consumption and a decrease in energy expenditure due to a secondary lifestyle such as watching television or computer and video game use.
[7] Schwarz SM. Emedicine from WebMD. Obesity. Available at Accessed April 5th 2009.

6. In those children and adolescents who are obese, there is a dysfunction in the gut-brain-hypothalamic axis by means of the ghrelin/leptin pathway.
This has been known to play a role in abnormal appetite control, which leads to an increase in energy intake.
[7] Schwarz SM. Emedicine from WebMD. Obesity. Available at Accessed April 5th 2009.
This increase in energy intake can especially be seen in those with Prader-Willi syndrome, Cushing syndrome and drug induced obesity.

7. Ghrelin and Leptin
Ghrelin is a hormone that stimulates hunger (appetite stimulate) while leptin plays a key role in regulating energy intake and energy expenditure (appetite depressor).
Ghrelin levels increase before meals and decrease after meals. It is considered the counterpart of the hormone leptin, which is the overall satiety signal.
Leptin is produced by fat cells and most obese people have higher leptin levels than normal because of a higher number of fat cells.
[8] Wikipedia: the free encyclopedia: Ghrelin. Available at website: Accessed May 2nd.
[9] Wikipedia; the free encyclopedia: Leptin. Available at website: Accessed May 2nd 2009.
Adopted from Deepa Handu. Professors at BenU. Obesity Theory and Practice Application. Lecture 5: Childhood Obesity.

8. Ghrelin and Leptin
Leptin does not have the same satiety affect in obese individuals as it does in leaner individuals.
Leptin Resistance!
Ghrelin levels in the plasma of obese individuals are higher than those in leaner individuals.
Ghrelin does not decrease after a meal, it still very high which means it still stimulates appetite.
[8] Wikipedia: the free encyclopedia: Ghrelin. Available at website: Accessed May 2nd.
[9] Wikipedia; the free encyclopedia: Leptin. Available at website: Accessed May 2nd 2009.
Adopted from Deepa Handu. Professors at BenU. Obesity Theory and Practice Application. Lecture 5: Childhood Obesity.

9. However, excess intake, decrease energy expenditure, and hormonal disorders do not completely explain excess weight gain.
Most overweight children and adolescents have a family history of overweight and obesity with at least one or two parents, whom are overweight.
Nevertheless, it is both genetics, environmental and behavioral factors that play a role,which will be discussed later.
[7] Schwarz SM. Emedicine from WebMD. Obesity. Available at Accessed April 5th 2009.

10. Contributing Factors to Childhood Obesity
Such factors include:
Genetics
Behavioral factors such as:
Energy intake, physical activity, and sedentary behavior.
Environmental factors such as:
Home, school, and even childcare.
As childhood obesity continues to rise it is important to understand the contributing factors to this ever so large epidemic among children.

11. American Dietetic Association Evidence Based Library
Based on the American Dietetics Associations evidence based library, they have made a “map” outlining some of the plausible causes of childhood obesity and overweight status.
ADA- Factors Associated with Childhood Obesity
[10] American Dietetic Association: Evidenced based library. Factors associated with childhood overweight. Available at website: Accessed April 5th 2009
Some of the factors causing childhood obesity are social influences, parental resources, such as diet habits, weight attitudes, anthropometrics, social economic status, diet and physical activity management strategies which include eating out, restrictions, portion sizes as well as pressure to eat. In addition, there is parent and child relationship factors, the child’s psychological and behavioral characteristics, which influence their food and nutrient consumption as well as their physical activity participation [8].

12. C.W.

13. Patient Profile: CW
CW is an eight-year-old Hispanic male that was born on August 17th, 2000.
CW speaks fluent English, as this is his primary language.
He is attending school full time and is enrolled in the 3rd grade.
He has two older female siblings and two parents that have been divorced for four years now.

14. Living Arrangements
CW spends his afternoons at his mother’s house until 7 pm where the father will pick them up at this time.
The children then stay with their father until school the next day.
Weekends can vary as to which parent has the children.
CW’s mother is remarried and lives with her husband and her mother.
Father lives by himself.

15. Patient Profile: CW Past Medical History: Current Symptoms:
Attention Deficient Disorder (ADD)
Diagnosed two years ago.
Current Symptoms:
Excessive thirst
Excessive hunger
Inability to pay attention
Tiredness
Sleep apnea
He has been tested for Diabetes since his symptoms indicate this, but the test came back negative after his fasting blood glucose was 93 mg/dL.
3 different ways to diagnosis diabetes in children:
Signs and symptoms of Diabetes + casual plasma blood glucose of >/= 200 mg/dL
FBG >/= 126 mg/dL with signs and symptoms
2-hour PG >/= 200 mg/dl during an OGTT
Recommend this to be tested again using one of the other test!

16. Diabetes and Childhood Obesity
Rates for childhood obesity and type two diabetes are higher than ever.
The accumulation of excess body fat, particularly in the visceral area, has the potential to reduce the sensitivity to insulin in skeletal muscle, liver tissues, and adipose tissues also known as insulin resistance.
[7] Schwarz SM. Emedicine from WebMD. Obesity. Available at Accessed April 5th 2009.
This predisposes the adolescent or child to glucose intolerance and hypertrigyceridemia.

17. Risk Factors for Type 2 Diabetes in Youth
Obesity: Risk for diabetes increase two times for every 20% of excess body weight.
Puberty: Insulin Resistance falls by 30% in early puberty.
Family History: T2DM is associated strongly with family history.
Ethnicity: More prevalent in some ethnicities/minorities.
Adopted from Deepa Handu. Professors at BenU. Obesity Theory and Practice Application. Lecture 5: Childhood Obesity.

18. Weight History
CW has been overweight since birth tipping the charts at the 90th to 95th percentile.
Since his parents divorce when he was 4, his eating habits have only gone down hill and have become increasing worse.

19. Parent to Child Relationships
For CW, his underlying problem on his unhealthy eating habits and obese lifestyle has a great deal to do with his parents who have been divorced since he was four years of age.
A study that investigated the characteristics of the social environment and their potential risk on childhood obesity, found that lower social class status, lower expressive social support, and unmarried status of the caretaker were associated with a higher calorie intake and a higher weight for height score in the children being studied.
[11] Gerald LB, Anderson A, Johnson GD, Hoff C, Trimm RF. Social class, social support and obesity risk in children. Pediatrics. 2006; 20(3):

20. Parent to Child Relationships
Another study done by Strauss, investigated whether the association between the home environment and socioeconomic factors lead to the development of obesity and found that children who lived with single mothers were significantly (P < .05) more likely to develop obesity by the 6-year follow-up.
[12] Strauss RS, Knight J. Influence of the home environment on the development of obesity in children.
Pediatrics Jun;103(6):85.  
Although, CW does not have a single mother, he potential does have parents that live alone.
Therefore, family functioning really does have a lot to do with CW’s overweight status as well as other factors like excess dietary intake and leading a sedentary lifestyle.

21. Parents Medical History
The parent’s have no past medical issues; however, his mother used to be overweight until having gastric bypass surgery a few years back and the father is within normal weight status.
Mother states that one of his siblings is reported to be within normal weight limits while the other is reported to be underweight.

22. Nutritional Data Height: 5’0 feet Weight: 158 pounds BMI: 30.8
Above the 97th percentile for stature-for-age
Weight: 158 pounds
Above the 97th percentile for weight-for-age
Taken at doctors office at the end of February
BMI: 30.8
Above the 97th percentile for BMI-for-age
UBW: Varies since he is a child.
Gaining 1-2 pounds/month

23. Medications Drug Name Instructions Diet Nutritional Oral/GI Other
Ritalin
5 mg tab
Take with food, no later than 6 pm.
Food helps increase extent, but not rate of absorption.
Insure adequate calorie intake.
Limit Caffeine.
May cause:
-Anorexia
- Decrease weight
- Decrease Growth
Dry Throat
Nausea
Abdominal Pain
Nervousness
Insomnia
Tachycardia
Hypertension
Hypotension
Rash
Joint Pain
Drowsiness
Headache
No other meds are being taken- No M/V
CW is not experiencing any of the above complications that are associated with this drug and quite frankly, some of the symptoms he is experiencing are the opposite effect. This includes increase appetite and weight gain.
On the other hand, based on the above table, the only thing that needs to be limited from the diet is caffeine, which includes coffee and teas as well as ice cream, diet or regular soda (pop), chocolate pudding, chocolate ice cream, chocolate chips, milk chocolate, hot cocoa, chocolate cold cereal, and chocolate flavored syrup. CW is however, eating foods that do contain caffeine, which can be seen later on within his eating patterns [11].
[13] Pronsky ZM. Food Medication Interactions, 14th ed. Birchrunville, PA: Food-Medications Interactions;  

24. Lab Results Lab Test Normal Values Date Taken/Values Results
Triglycerides
< 150 mg/dL
2/20/09
135 mg/dL
Normal
Fasting Blood Glucose
< 100 mg/dL
93 mg/dL
Total Cholesterol
< mg/dL
156 mg/dL
LDL
< 100
80 mg/dL
HDL
> 40
43 mg/dL
All of CW’s labs came back within the normal range. His fasting blood glucose level was also within normal but still on the high side.
Therefore, it is important to continue to monitor this since he is still experiencing diabetic like symptoms.
However, with diet and lifestyle change, there will most likely be an improvement in this as well as his other lab values.
Although, his cholesterol lab values such as total cholesterol, LDL, HDL, and even triglycerides were within their normal ranges, they were still on the relatively high side of normal.
Again, medication at this time is not needed because diet should be able to improve this where they can be towards the lower side of normal.
Interestingly enough, it was odd to not see some of this lab values within normal since his diet is not a healthy and nutritious diet.
In addition, low high-density lipoprotein levels can contribute to increase risk of premature coronary artery disease which can be see in the child’s and adolescent adult life.
In addition, excess body fat can lead to various other forms of chronic disease and again can be carried into adult life this decreasing life expectancy [7]

25. Typical Day for C.W. Breakfast Lunch Dinner Snack
2 cups of cereal, which is either Cookie Crisp or a peanut butter chocolate cereal with one cup of 2% milk
Some days he may have waffles or French toast sticks with syrup and butter.
Occasionally scrabbled eggs
Drinks about 2 cups of juice a day such as apple or orange juice with breakfast
Lunch
Lunch consists of the hot lunch at school, which may be:
2 slices Pizza with fries
6 Chicken nuggets with fries
Macaroni and cheese
1 Salisbury steak
1 cup mashed potatoes
He only drinks chocolate milk at school.
- Mother will sometimes pack him fruit and cheese to eat with his lunch but she is not sure if he eats it.
Dinner
Usual at mother house:
1 Chicken breast
1 cup Rice
½ cup Vegetables
2 slices of bread with 4 tbsp of butter.
May drink some water at dinner ~ 1 cup
Snack
After School Snack:
Animal crackers
Graham crackers
Yogurt with soda.
Evening Snack: When father picks children up around 7 pm every night, he likes to “treat” them with an ice cream sundae.

26. Nutrient Analysis of a Typical Day
Based on the nutrient analysis:
Total caloric intake: 3400 kcals
Protein: grams
Fat: 140 grams of fat
Sodium: 4,520 mg.
Vitamin and Minerals: most vitamins and minerals meet 100% of the recommended intake except Vitamin E.
Carbohydrates: 50%
12.9 servings
9 from simple carbohydrates
Protein: 11%.
5.0 servings of lean protein sources
Fat: 38%
23 servings
Fruit: 3.5 servings
Vegetables: 3 servings
Milk: 1 servings
Based on the MyPyramid, his intake is high in carbohydrates, and fats while lacking fruits, vegetables, and lean meats

27. Personnel Food Habits
CW eats breakfast and dinner at his mother’s house and lunch at school.
When the father comes to pick up the kids in the evening, he likes to “treat” the kids to a snack which is usually around 7:00 pm.
Ice cream

28. Personnel Food Habits Mother states:
CW rarely skips a meal and will often eat late at night.
Food dominates his life and she worries that he has lost all control over eating.
Does not chew his food but simply swallow’s food whole.
Eats 3 solid meals a day with snacks but has seen him sneaking food into his bedroom or other areas of the house in order to eat more food.

29. Personnel Food Habits
CW has no known food allergies or cultural restrictions.
He will eat out at least 2 times a week at fast food restaurants.
Mother prepares most meals and occasional he will eat ethnic Hispanic foods at fathers house over the weekends.
Eating together rarely occurs as the mother prepares the food and lets the children eat for themselves.
Mother and father do all grocery shopping for CW.

30. Personnel Food Habits
When meeting with parents together at the second visit without CW, RD determined that child will eat one thing at mom’s house and then tell father that he does not like that food when served at fathers house.

31. Current Diet Order
After meeting with the RD on March 2nd 2009, she prescribed the follow diet:
kcal meal plan
50% from complex carbohydrates
25% lean protein
25% from monounsaturated and polyunsaturated fat
Saturated fats: < 7-8% of fat calories
20 grams of fiber per day.
The child has not followed any diet or dietary recommendation previous.
On the other hand, after his mother received gastric bypass surgery, she classifies food as “bad” or “good” and will try and restrict him from the “bad” foods.
Using 1450 kcals
50% from carbohydrates = 725 calories/4 = 181 grams/15 = 12 servings
25% from fat = calories/9 = 40 grams/5 = 8 servings
25% from protein = 362 calories/4 = 90 grams /7= 13 servings

32. Diet Recommendations Education: Nutrition Goals:
Family Based counseling techniques
Role of six food groups for growth, development as well as disease prevention.
Sources of energy dense foods and beverages.
Appropriate portions for children.
Role of Physical activity in health and weight management.
Nutrition Goals:
Aim for daily consistency in intake
Decreasing portion sizes
Screen time: 1 Hour per day
Physical activity: 60 minutes per day

33. 1800 Kcal Diet
50% from carbohydrates = 900 calories/4 = 225 grams/15 = 15 servings.
Diet Recall = 13 servings (9 from simple carbohydrates)
25% from fat = 450 calories/9 = 50 grams/5 = 10 servings.
Diet Recall = 23 servings
25% from protein = 450 calories/4 = grams /7= 16 servings
5 servings from lean meats
Using IBW = kcal/kg = 900kcal kcal
Not appropriate to use his ideal since he is growing
Adj wt: 115 # = kcal
Again not appropriate because he is growing and having IBW in the equation may not provide him with adequate calories
Want him to grow into his current weight.

34. Diet Rationale
The diet rationale is appropriate based on current recommendations for treating pediatric obesity.
Based on the American Dietetic Association Evidence Based Library, they recommend the use of a
1)Treatment Focus Plan
Dietary interventions
Physical activity interventions
Behavioral interventions
Adjunct therapies
2)Treatment Format Plan
Educating children and parents together versus child alone
Prescribed diet plan and nutrition education
Group versus individuals counseling
Peer counseling
[14] American Dietetic Associations Nutrition Care Manual. Treating childhood overweight. Available at website: Accessed April 4th 2009 

35. Dietary Interventions
Dietary Interventions include the use of:
1) Balanced macronutrient diets
1)By age Groups
2)Selected Diets
2) Altered macronutrient diets

36. Balanced Macronutrient Diets
Balance macronutrient diets are based on the child’s age group or selected diet approaches.
Based on CW’s age, the ADA evidence based library states:
“A prescribed diet was considered to be macronutrient "balanced" if the macronutrient composition fell within DRI ranges: ‘Adults should get 45 percent to 65 percent of their calories from carbohydrates, 20 percent to 35 percent from fat, and 10 to 35 percent from protein. Acceptable ranges for children are similar to those for adults, except that infants and younger children need a slightly higher proportion of fat (25 %-40%).’ “
[15] American Dietetic Associations Nutrition Care Manual. Pediatric weight management: dietary interventions: Available at website: Accessed April 4th  

37. Selected Diet Approaches
Stop Light Diet
2) Food Guide Pyramid

38. Stop Light Diet
The Stoplight Diet is ideal for those age 6 to 12 years of age as a dietary component commonly used in behavioral interventions.
The diet classifies food as green, yellow, and red; much like a stoplight.
The energy goals for this diet is around 900 to 1,300 kcal/day with daily recording of all food and drinks consumed.
According to the evidence library, they grade this with a 1, which is good.
[16] Kirk S, Scott B, Daniels S. Pediatric obesity epidemic: treatment options. J Am Diet Assoc. 2005;105:  

39. Stop Light Diet
Green-light foods are low calorie, high fiber foods with no restrictions placed on how much to eat.
Yellow-light foods are viewed as those essential to a healthy, well-balanced diet, but because they are considered to be a higher nutrient density they are to be eaten in moderation.
Red-light foods are those that are high in fat or simple in sugars and are limited to no more than four servings per week and have to be eaten away from home.
[16] Kirk S, Scott B, Daniels S. Pediatric obesity epidemic: treatment options. J Am Diet Assoc. 2005;105:  

40. Food Guide Pyramid
Research on the pre-2005 Food Guide Pyramid focuses primarily on the use of the pyramid as an assessment tool, not as an intervention tool to treat overweight in children.
There is not enough research to judge the effectiveness of using the pre-2005 Food Guide Pyramid as an intervention tool to treat overweight in children.
[17] American Dietetic Associations Nutrition Care Manual. What is the evidence to support the Food Guide Pyramid as an approach to limiting calorie/food intake in children? Available at website: Accessed April 4th 2009 
However, it serves as a great tool for educating parents and children on healthy eating habits.

41. Altered Macronutrient Diets
Low Fat
Altered Carbohydrates
Altered Protein
[14] American Dietetic Associations Nutrition Care Manual. Treating childhood overweight. Available at website: Accessed April 4th 2009 
Low Fat: No research was identified in which a diet with less than 20% of total daily energy intake from fat was used to treat childhood overweight. There is insufficient evidence to make a judgment on the effectiveness of using a low-fat diet (under 20% of total daily energy intake) as a means to treat childhood overweight.
Grade V-Not assignable
Altered Carbohydrates: Use of an ad libitum low-glycemic diet may be effective for modest short-term weight loss in children (ages six to 12) and may be effective for longer-term weight loss in adolescents.
Grade III- Limited
Altered Protein: There is insufficient evidence to suggest that high-protein, low-carbohydrate, very-low-calorie diets (protein-sparing modified fast) result in greater long-term weight loss in children, compared to balanced macronutrient diets at the same calorie intake level.
Grade V

42. Physical Activity
Receiving a grade score of one, the evidence based library indicates that “using a program to increase physical activity as part of a pediatric weight-management program results in significant improvements in weight status and adiposity in children and adolescents”
[18] American Dietetic Associations Nutrition Care Manual. What is the effectiveness of using a program to increase physical activity as a part of an intervention program to treat childhood overweight? Available at website: Accessed April 5th 2009 

43. Treatment Focus-Behavioral
Behavioral interventions include the use of family-based counseling that includes parent training as part of a multi-component pediatric weight management program which results in significant reductions in weight status and adiposity in children 12 years and younger.
[19] American Dietetic Associations Nutrition Care Manual. What is the effectiveness of family-based counseling including parent training or modeling as part of a multicomponent pediatric weight management program to treat overweight in children (ages 6-12)? Available at website: Accessed April 5th  

44. Treatment Focus Prescribed Diet and Nutrition Education
It has been shown that including a prescribed diet plan as part of a multi-component weight-management program results in improvements in adiposity in children in both the short-term and longer-term (more than one year).
[20] American Dietetic Associations Nutrition Care Manual. What is the effectiveness of using a prescribed dietary plan as part of an intervention program for child (ages 6-12) overweight? Available at website: Accessed April 5th  

45. Other Recommendations
Research has shown that eating dinner as a family has been associated with a more healthful diet; more fruits and vegetables, fewer fried foods, less soda, less fat and more micronutrients.
Furthermore, I would encourage the parents to be a role model in healthy eating behaviors as well as partaking in physical activities with the child.
Parental modeling for both healthy eating habits and physical activity has been shown to help shape children’s values, beliefs, and behaviors about healthy eating and engaging in physical activity.
[21] Gillmann MW, Rifas-Shiman SL, Frazier AL, Rockett HR, Camargo CA Jr, Field AE, Berkley CS, Colditz GA. Family dinner and diet quality among children and adolescents. Arch Fam Med. 2000; 9:  
[22] Ritchie LD, Welk G, Styne D, Gerstein D, Crawford P. Family environment and pediatric overweight

46. Other Recommendations
I would recommend the parents to write a list of meals together that the child can eat within their household in order to provide the same meals/foods at each house.
Educate the father on ways to provide “treats” that are not foods, such as going for a walk or a movie, taking them to the park or the pet shop, etc.
This way the child cannot say well I do not eat that at mom’s house and vice versa.
In addition, with the mother’s new husband, the father feels that my treating the children to “treats” that they will still continue to like him better than his ex-wife’s new husband.

47. Sample Meal Plan-1800 kcal Breakfast: 1 egg or ¼ cup egg substitute
1 slice whole wheat bread, toasted
1 tsp margarine
6 ounces of low fat yogurt
1 medium orange
Lunch:
3 ounces of lean deli meat
1 ounce of low fat cheese
2 slices of whole wheat bread
Lettuce, tomato, onion, etc
2 tsp mayonnaise
1 medium apple
1 ounce of light chips
Dinner
5 ounces of grilled, broiled or baked boneless skinless chicken
¾ cup cooked rice
1 dinner roll (whole wheat)
Steamed assorted vegetables
1 small salad with lettuce tomatoes, onions, and cucumbers
2 tbsp of low fat salad dressing
1 tsp margarine
Snack
1 cup of skim milk
3 graham cracker squares
½ cup of unsweetened applesauce

48. Short Term Goals for C.W. and Parents
Aim for a healthy well rounded diet
Increase fruits and vegetables to three to five per day
Increase low fat milk consumption
Decrease fast food consumption by limiting to once per week
Decrease soda and sugary beverage consumption to once a week
Increase physical activity to one hour per day
Decrease TV viewing time to one hour per day
Have divorced parent’s work together in planning meals and grocery list in order to have the same foods at both homes.
Work on portion control
Work on having the parents pack the child’s lunch to school every day

49. Long Term Goals for C.W. and Parents
Weight Maintenance
Improved diabetic symptoms
Ability for CW to plan his own healthy meals
Want CW to know the difference between healthy vs. not so healthy foods so he can continue to maintain his weight into adulthood.
Parents are very motivated to help their child overcome his compulsive eating in order to achieve an appropriate weight for his age.
They are willing to take whatever steps are necessary to improve their child’s overall health even if it comes to them having to work together to accomplish this. However, there motivation level is very high because they want their son to succeed.
This can been seen by their willingness to work together on this issue.
An issue that may interfere with the child’s success is the parent’s lack of communication and unwillingness to work together when it comes to meal planning.
It may turn out that they end up overfeeding the child as it has happen before due to lack of interaction among each other.

50. ADIME NOTE: Assessment
CW is considered to be at a moderate to high nutritional risk due to an excess of body weight for his height and age.
He is far above the 97th percentile when plotted on a growth chart for BMI for age.
He consumes large amounts of food and eats all throughout the day.
He has diabetic symptoms and although he tested negative for diabetes he could still develop diabetes if his eating patterns continue.

51. ADIME: Diagnosis P: Excessive Oral Food/Beverage Intake (NI-2.2)
E: Related to food and nutrient knowledge deficit, lack of access to healthy food choices, inability to refuse or limit offered foods, lack of food planning, purchasing, and preparation skills, unaware of being full, and uninterested in reducing intake.
S: Diabetic related symptoms such as polyphagia, polydypsia, and lethargy. Patient is experiencing weight gain of 1-2 pounds per month and is considered obese as indicated by CDC growth charts. Intakes of large portions of food and beverages that are of high caloric density, in addition to episodes of binge eating, with frequent visits to fast food restaurants.

52. ADIME: Intervention
Food and Nutrient Delivery: Modified distribution, type, or amount of food and nutrients within meals or at a specified time.
Nutrition Education: Recommended Modifications
Nutrition Counseling: Stages of changes and Goal Setting

53. ADIME: Monitoring/Evaluating
Total energy intake, social support within the home, portion control, planned meals and snacks, food selection and preparation, and monitor growth and development.

54. Certificate Opportunity
June 15-17, 2009
Certificate of Training in Childhood and Adolescent Weight Management program.
Hyatt Regency Crown Center, 2345 McGee Street, Kansas City, Missouri.
For registration information and to view the certificate requirements, timeline, registration deadlines and agenda go to:
For a list of Certificate of Training in Adult Weight Management programs along with registration information, certificate requirements, timeline, registration deadlines and agenda, go to:

55. THANK YOU! Sincerely, Erica Timmermann

56. References
[1] Centers for Disease Control and Prevention. Overweight prevalence. Available at website: Assessed April 3rd 2009, 2009.
[2] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results Illinois 2007 dietary behaviors percentage of students who were obese. Available at website: Assessed April 3rd 2009, 2009.
[3] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results Illinois 2007 dietary behaviors percentage of students who were overweight. Available at website: Assessed April 3rd 2009, 2009.
[4] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results chicago, il 2007 percentages of student who were obese. Available at website: Assessed April 3rd 2009, 2009.
[5] Centers for Disease Control and Prevention YRBSS. Youth online: comprehensive results chicago, il 2007 percentages of students who were overweight. Available at website: Assessed April 3rd 2009, 2009.
[6] Centers for Disease Control and Prevention. Defining childhood overweight and obesity. Available at website: Accessed April 5th 2009
[7] Schwarz SM. Emedicine from WebMD. Obesity. Available at Accessed April 5th 2009.

57. References
[8] Wikipedia: the free encyclopedia: Ghrelin. Available at website: Accessed May 2nd. [9] Wikipedia; the free encyclopedia: Leptin. Available at website: Accessed May 2nd [10] American Dietetic Association: Evidenced based library. Factors associated with childhood overweight. Available at website: Accessed April 5th [11] Gerald LB, Anderson A, Johnson GD, Hoff C, Trimm RF. Social class, social support and obesity risk in children. Pediatrics. 2006; 20(3): [12] Strauss RS, Knight J. Influence of the home environment on the development of obesity in children. Pediatrics Jun;103(6):85. [13] Pronsky ZM. Food Medication Interactions, 14th ed. Birchrunville, PA: Food-Medications Interactions; [14] American Dietetic Associations Nutrition Care Manual. Treating childhood overweight. Available at website: Accessed April 4th 2009 [15] American Dietetic Associations Nutrition Care Manual. Pediatric weight management: dietary interventions: Available at website: Accessed April 4th [16] Kirk S, Scott B, Daniels S. Pediatric obesity epidemic: treatment options. J Am Diet Assoc. 2005;105: [17] American Dietetic Associations Nutrition Care Manual. What is the evidence to support the Food Guide Pyramid as an approach to limiting calorie/food intake in children? Available at website: Accessed April 4th 2009

58. References
18] American Dietetic Associations Nutrition Care Manual. What is the effectiveness of using a program to increase physical activity as a part of an intervention program to treat childhood overweight? Available at website: Accessed April 5th 2009 
[19] American Dietetic Associations Nutrition Care Manual. What is the effectiveness of family-based counseling including parent training or modeling as part of a multicomponent pediatric weight management program to treat overweight in children (ages 6-12)? Available at website: Accessed April 5th  
[20] American Dietetic Associations Nutrition Care Manual. What is the effectiveness of using a prescribed dietary plan as part of an intervention program for child (ages 6-12) overweight? Available at website: Accessed April 5th  
[21] Gillmann MW, Rifas-Shiman SL, Frazier AL, Rockett HR, Camargo CA Jr, Field AE, Berkley CS, Colditz GA. Family dinner and diet quality among children and adolescents. Arch Fam Med. 2000; 9:  
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