NDD10603

NDD 10603LECTURE 7: CHILD AND

PREADOLESCENT NUTRITION

DR. SHARIFAH WAJIHAH WAFA BTE SST WAFASchool of Nutrition and Dietetics

Faculty of Health [email protected]

KNOWLEDGE FOR THE BENEFIT OF HUMANITY

SCHOOL OF NUTRITION AND DIETETICS . FACULTY OF HEALTH SCIENCES

TOPIC LEARNING OUTCOMES

• At the end of this lecture, the students should be able to:

1. Categorise BMI for children according to WHO growth reference 2007

2. Determine the nutrient requirement for children

3. Discuss the short term and long-term of childhood obesity

4. Define adiposity rebound


Course Outline1. Introduction– Growth and development– Physiological development– Cognitive development

2. Eating behaviour3. Energy and Nutrient Needs4. Common Nutrition Problem5. Childhood Obesity


Definitions of the Life Cycle Stage

• Middle childhood—between the ages of 5 and 10 years

• Preadolescence—ages 9 to 11 years for girls; ages 10 to 12 years for boys

• Both may also be termed “school-age”


Normal Growth and Development

• Measurement techniques– Growth velocity will slow down during

the school-age years– Should continue to monitor growth

periodically–Weight and height should be plotted on

the appropriate growth chart


Normal Growth and Development

• WHO Growth References– Tools to monitor the growth of a child for

the following parameters• Weight-for-age• Height-for-age• Body mass index (BMI)-for-age

– Can be downloaded from WHO website at www.who.int/childgrowth

http://www.who.int/childgrowth


Physiological Development in School-Age Children

• Muscular strength, motor coordination, & stamina increase

• In early childhood, body fat reaches a minimum then increases in preparation for adolescent growth spurt

• Adiposity rebounds between ages 6 to 6.2 years

• Boys have more lean tissue than girls


Adiposity Rebound• Preschool years-critical period for

obesity prevention. • Children’s Body Mass Index (BMI) is

normally lowest around age 4 to 6.• “Adiposity rebound” occurs after this

age. • If “adiposity rebound” occurs before

age 5.5 years, increased risk for obesity later in life.


Adiposity Rebound• Early BMI rebound may be related to

infants who were exposed to gestational diabetes during foetal development and consequently have high birth weights.

• BMI rebound after age 7 is considered late.


Adiposity Rebound


Cognitive Development in School-Age Children

• Self-efficacy…the knowledge of what to do and the ability to do it

• Change from preoperational period to concrete operations

• Develops sense of self• More independent & learn family

roles• Peer relationships become important


Development of Feeding Skills

• motor coordination & improved feeding skills

• Masters use of eating utensils• Involved in food preparation• Complexities of skills with age• Learning about different foods,

simple food prep and basic nutrition facts


Eating Behaviors• Parents & older siblings influence

food choices in early childhood with peer influences increasing in preadolescence

• Parents should be positive role models

• Family meal-times should be encouraged

• Media has strong influence on food choices


Feeding Behaviors of Toddlers

• Rituals in feeding are common• May have strong preferences &

dislikes• Food jags common• Serve new foods with familiar foods

& when child is hungry• Toddlers imitate parents & older

siblings



Body Image and Excessive Dieting

• The mother’s concern of her own weight issues may increase her influence over her daughter’s food intake

• Young girls are preoccupied with weight & body size at an early age


Body Image and Excessive Dieting

• The normal increase in adiposity at this age may be interpreted as the beginning of obesity

• Imposing controls & restriction of ”forbidden foods” may increase desire & intake of the foods


Media Influence

• commercials aired during Saturday morning television programming and found that 49% of all advertisements were for food.

• Of these food advertisements, 91% were for foods or beverages high in fat, sodium, or added sugars or were low in nutrients.


• STUDY 1: examine the relationships among children’s adiposity, child-feeding practices, and children’s responsiveness to energy density.

• RESULT:– children of parents who imposed

authoritarian controls on their children’s eating were less likely to be responsive to energy density.• children were not able to listen to internal cues in

energy regulation.

Body Image/Excessive Dieting



• Study 2: “restrictive” eating practices

• RESULT: – begin as early as the preschool age.– The more the mother is concerned with her

own weight and with the risk of her daughter becoming overweight, the more likely she is to employ restrictive child-feeding practices.

• Early “dieting” may actually be a risk factor for the development of obesity???WHY??



• Dieting ------ restrictions-----controlling child-feeding practices------restrict children’s intake.– ignore internal cues of hunger and

satiety.– contribute to the onset of obesity and– beginnings of eating disorders

Energy and Nutrient Needs of School-Age

Children



Energy• depends on the child’s – activity level and – body size.

• Equations for estimating energy requirement based on a child’s – Gender– age, – Height and weight, and – physical activity level (PAL).


Energy• Estimated energy expenditure (EER):

total energy expenditure plus kilocalories for energy deposition.

• Categories of activity are defined in terms of walking equivalence. – For example:• an 8-year-old girl who weighs 25.6 kg and is

128 cm tall will require 1360 kilocalories per day if sedentary, 1593 kcal/day if she is low-active, 1810 kcal/day if active, and 2173 kcal/day if very active.


• RNI for children– 4-6 years: 23g/day– 7-9 years: 32g/day

• RNI for adolescents– Boys • 10-12 years: 45g/day

– Girls• 10-12 years: 46g/day

Protein


• RNI for children– Boys

• 4-6 years: 30-45g/day• 7-9 years: 40-59g/day

– Girls• 4-6 years: 29-43g/day• 7-9 years: 35-53g/day

• RNI for adolescents– Boys

• 10-18 years: 57-86g/day– Girls

• 10-12 years: 46-69g/day

Fat


Common Nutrition Problems• Iron deficiency– Less common in children than in

toddlers– Dietary recommendations to prevent:

encourage iron-rich foods • Meat, fish, poultry and fortified cereals• Vitamin C rich foods to help absorption


• Dental caries– Seen in half of children aged 6 to 8– Reduce dental caries by limiting sugary

snacks & providing fluoride– Choose fruits, vegetables, and grains– Regular meal and snack times– Rinse (or better yet, brush the teeth)

after eating

Common Nutrition Problems


• Overweight and Obesity in School-Age– According to National Health and Morbidity

Survey III (2006) estimated the overweight prevalence among schoolchildren aged 7-13 years was 5.9-6.8%.

– Overweight and obese children have an increased risk to stay obese towards adulthood and more likely to develop non-communicable disease like diabetes mellitus and cardiovascular disease at a younger age.

Prevention Of Nutrition-related Disorders In School-age Children

31

Prevalence of overweight children in Malaysia (NHMS ΙΙΙ, 2006)

2.3%

Sabah

Sarawak

2.9%

5.0%

5.9%

9.1%

7.1%

6.1%

6.1%

5.2%

7.2%

6.5%

4.0%

5.4% 5.4%

6.0%


• Characteristics of Overweight Children

• Predictors of Childhood Obesity• Assessment of Overweight and

Obesity• Treatment of Overweight and Obesity

Overweight and Obesity in School-Age


• Compared to normal weight peers, overweight children:– Are taller– Have advanced bone ages – Experience earlier sexual maturity – Look older– Are at higher risk for obesity-related

chronic diseases

Characteristics of Overweight Children


Health consequences of obesity

Short term• Psychological co-

morbidity• Cardiovascular risk

factors• Asthma• Chronic

inflammation

Long term• Persistence of

obesity• Persistence of

cardiovascular risk factors

• Premature morbidity and increased risk of premature mortality


Predictors of Childhood Obesity

• Age at onset of BMI rebound – Normal increase in BMI after decline– Early BMI rebound, higher BMIs in

children later

• Home environment–Maternal and/or Parental obesity

predictor of childhood obesity


Other predictors:• Child’s home environment. • Parental obesity is associated

with an increased risk of obesity in children. – In one study, parental obesity doubled

the risk of adult obesity for both obese and non-obese children less than 10 years of age.

– The connection between parental obesity and obesity in children is likely due to genetic as well as environmental factor


Assessment of Overweight and Obesity

• Body mass index-for-age percentile – Overweight: >85th but < 94th percentile,

and a – Obesity: >95th percentile– 99th-percentile: increased risk of obesity-

related health consequences.• Other components of assessment include– evaluation of the child’s medical risk:• parental obesity, and• behavior risk

– dietary and physical activity behaviors.


Prevention and Treatment of Overweight and Obesity

• Expert’s recommend a 4-stage approach:• The four stages:– Stage 1: Prevention Plus– Stage 2: Structured Weigh Management (SWM)– Stage 3: Comprehensive Multidisciplinary

Intervention (CMI)– Stage 4: Tertiary Care Intervention (reserved

for severely obese adolescents)




• Treatment consists of a multi-component, family-based program consisting of:– Parent training– Dietary counseling/education– Physical activity– Behavioral counseling


Goal of treatment• Overweight: weight maintenance or a

slowing of the rate of weight gain until a BMI for- age percentile <85th is achieved.

• Obese: weight maintenance or gradual weight

• loss of no more than 0.5kg per week until the BMI-for-age percentile drops to <85th.

• Extremely obese: Weight loss not to exceed to 1kg per week until a BMI-for-age percentile of <85th is achieved


MASCOT

Randomised controlled trial (RCT) of a novel, practical, evidence based, dietetic intervention in

obese children of primary school age

44


Results• Participants were recruited from November

2008 to April 2009• 107 families enrolled in the study

completed the questionnaire• 54 were male (50%) and 53 were female

(50%)• 103 Malays (96%) and four Indians (4%).• Obese children age 10 • Mean BMI z score at baseline was greater

than 3 in both groups

46

Change in weight from baseline to 6 months

47


Nutrition and Prevention of CVD in School-Age Children• Acceptable range for fat is 25% to

35% of energy for ages 4 to 18 year• Include sources of linoleic (omega-

6) and alpha-linolenic (omega-3) fatty acids

• Limit saturated fats, cholesterol & trans fats


Nutrition and Prevention of CVD in School-Age Children• Increase soluble fibers, maintain

weight, & include ample physical activity

• Diet should emphasize:– Fruits and vegetables– Low-fat dairy products–Whole-grain breads and cereals– Seeds, nuts, fish, and lean meats


Dietary Supplements• Supplements not needed for

children who eat a varied diet & get ample physical activity

• If supplements are given, do not exceed the RNI.


Fluid and Soft Drinks• Preadolescents sweat less during

exercise than adolescents & adults • Provide plain water or sports drinks

to prevent dehydration• Limit soft drinks because they

provide empty calories, displace milk consumption & promote tooth decay


Recommended versus Actual Food Intake

• Saturated fat—intake is 12.6% of calories (recommend <7%)

• Total fat—intake excessive in African American boys & girls & Mexican-American girls

• Caffeine—increasing because of soft drink consumption

• Fast food—30.3% of children consume fast food each day


Physical Activity• It is recommended that children engage in at

least 60 minutes of physical activity every day.

• Strategies for parents include:– Set a good example by being physically active

themselves and joining their children in physical activity.

– Limit television and video/DVD watching, computer and video game playing, time at the computer, and other inactive forms of play by alternating with periods of physical activity.


Determinants of Physical Activity

• Determinants may include:– Girls are less active than boys– Physical activity decreases with age– Season & climate impact level of

physical activity– Physical education classes are

decreasing


Organized Sports • Participation in organized sports

linked to lower incidence of overweight

• AAP recommends:– Participation in a variety of activities– Organized sports should not take the

place of regular physical activity– Emphasis should be on having fun and

on family participation rather than being competitive

57

Compliance is GREATER with home based versus group-based activity

0

20

40

60

80

100

Sess

ions

Com

plet

ed (%

)

* P<0.05 group-based vs home-based.Month

Home-basedGroup-based

***

***

Perri et al. J Consult Clin Psychol 1997;65:278. Copyright 1997 by the American Psychological Association. Reproduced with permission.

1 2 3 4 5 6 7 8 9 10 11 12

59

Kesan Mengurangkan Tingkahlaku Sedentari vs Meningkatkan Aktiviti Fizikal terhadap berat badan di

kalangan kanak-kanak 6-12 tahun

-25

-20

-15

-10

-5

0

0Masa (bulan)

Mengurangkan tingkahlaku sedentari

Peru

bahn

per

atus

an b

erle

biha

n be

rat b

adan

Meningkatkan Aktiviti Fizikal

Epstein et al. Health Psychol 1995;14:109.

4 8 12

60

Mengurangkan menonton TV dapat mengurangkan BMI di kalangan kanak-kanak

-7

-6

-5

-4

-3

-2

-1

0

Robinson JAMA 1999;282:1561.

6-monthintervention

Control

Perubahan menonton TV (jam/minggu)

P<0.001

00.10.20.30.40.50.60.70.8

6-monthintervention

Control

Perubahan BMI (kg/m2)

P=0.002


Outside Influences• School-age children spend more time

away from home. • Peer influence becomes greater as

the child’s world expands beyond the family.

• Children may suddenly request a new food or refuse a previous favorite food, based on recommendations from a peer.


KEY POINTS1. School-age and preadolescent children continue

to grow at a slow, steady rate until the adolescent growth spurt.

2. Monitoring BMI-for-age percentiles is important for screening for overweight or underweight.

3. Complications of overweight and obesity in children and adolescents, such as type 2 diabetes mellitus, are increasing.

4. Sedentary lifestyles and limited physical activity are contributing factors to the increase in childhood overweight.

THANK YOU!


NDD10603

Health & Medicine