Professional Documents
Culture Documents
Presented to
the Faculty of the Center for Graduate Studies
Adventist University of the Philippines
Professor: Miriam Razon-Estrada, RND, DrPH
Submitted by
Thadee Katembo
TABLE OF CONTENTS
Chapter Page
I. THE PROBLEM AND ITS BACKGROUND 3
Introduction 3
The Problem 5
Significance of the study 5
Scope and Limitations 6
Definition of the Key Terms 6
II. FACTORS AND CONSEQUENCES OF OVERWEIGHT AND 8
UNDERWEIGHT FOR CHILDREN
Factors and complications of overweight and obesity 8
Management or Intervention 14
Chapter I
Introduction
3
Nowadays, weight management is a serious issue, regardless age and gender. Those who are in a
particular risk in terms of nutritional problems are mostly children and women. When the problem begins
in the childhood, if not solved early and efficiently, the risk of sequels is higher in the following years of
life. At the other hands, the nutritional problem for the mother cannot be without implications to the child
In 2006, worldwide estimates indicated that 300 million people were obese and 750 million more
were overweight (McArdle, Katch&Katch, 2007). However, obesity is no more only a health problem in
adult people, but current data reveal that children are not saved. WHO specifies that at least 20 million
children under the age of 5 years were overweight globally in 2005. (WHO, 2006) In parallel to the
development in adults, the prevalence of overweight children and adolescents is also increasing
worldwide, illustrating that children and adolescents are part of the worldwide epidemic of obesity.
The obesity “epidemic” began in the industrialized world but it is now also spreading to developing
countries. In many countries, about 15 to 35% of the children and adolescents are now classified as being
In developing countries, obesity coexists with undernutrition, with prevalence rates higher in
urban than in rural population. (McArdle, Katch and Katch, 2007). This duality underweight-overweight
make the burden heavier in developing countries than develop countries. This double burden of
malnutrition refers to the dual burden of under- and overnutrition occurring simultaneously
themselves toward a world in which sustaining development and eliminating poverty would have
the highest priority. The increased recognition of the relevance of nutrition as a basic pillar for
social and economic development placed childhood undernutrition among the targets of the first
Millennium Development goal to "eradicate extreme poverty and hunger." The specific target
4
goal is to reduce by 50% the prevalence of being underweight among children younger than 5
important public health problem and its devastating effects on human performance, health, and
17.6% in 2015, and the number of underweight children was projected to decline from 163.8
million in 1990 to 113.4 million in 2015. In developed countries, the prevalence was estimated
to decrease from 1.6% to 0.9%. In developing regions, the prevalence was forecasted to 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
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
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
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.
5
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.
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
Weight management for children is a very important topic for parents and health
professionals.
2. For health professionals. The best prevention of weight management problems starts in
The concept of children being wide ( up to 18 years), this presentation has a special
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
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 0–59 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
7
7. Wasting. For children aged 0–59 months, using the standard of NCHS/WHO, it refers to
the index weight/height below minus two standard deviations from median weight for
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
9. Stunting . For children aged 0–59 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
Chapter II
The present chapter describe briefly the main contributing factors to the double burden of
Factors
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
children’s and adolescent’s food preferences. Infants have an innate preference for sweet
and salty flavours whereas bitter and sour preferences are acquired. Children consume
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
4. Parental restriction of childhood eating. Parents who overly control or restrict their
child’s intake in an effort to prevent obesity can produce negative and unintended effects
on children’s food 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 child’s eating behavior more than families without
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
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
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
Without being exhaustive, the following can be considered among the main factors of
1. Low birth-weight (<2,500 g) was strongly associated with underweight in relation with the
height of mother.
2. Non adequate breast feeding and complementary feeding , food intake deficiency coupled
with poverty
5. Bad quality of water in households coupled with diarrhoea and other infectious diseases
Chapter III
Treatment of overweight and obese patient (eventually even for underweight) is a two-
It has been clear that the first step in the treatment process is to access the child’s and
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
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).
The WHO Global Database on Child Growth and Malnutrition uses a Z-score cut-off
point of <-2 SD to classify low weight-for-age, low heightfor-age and low weight-for-height as
moderate and severe undernutrition, and <-3 SD to define severe undernutrition. The cut-off
In children aged 6–59 months, an arm circumference less than 110 mm is also indicative
of severe acute malnutrition ( WHO, 1997). The MUAC measure is a long strip with a series of
colour bands. When measured properly against a bare upper arm, the gauge provides a number
Dietary Assessment
A global assessment of the child’s and family’s eating habits should be performed to
identify food preferences and eating patterns through an interview with the child or teenager as
well as the parent, and with food records and a food frequency check list. Special attention
should be paid to sweetened beverage and juice consumption, meals consumed outside the home
13
(school lunch and restaurant dining), prepared foods brought into the house and family food
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.
An assessment the child’s 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 child’s
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).
changes is an important measure of whether the weight management program will be successful.
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.
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
*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.
addressing nutritional, physical activity, and psychosocial issues offers the best chance at
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
behaviours and their relation to chronic diseases, modification of the home/school choices, self
b- Motivational interviewing
ambivalence of wanting to modify lifestyle behaviours that many patients and their families
discrepancies between their current behaviour and desired goals, acknowledging ambivalence
rather than ignoring it. Utilizing an emphatic interactive listening style to increase the patients’
16
and families’ motivations, the practitioner actively elicits the patients’ articulation of behavior
change.
Here are several different dietary approaches to help change children’s, adolescents’ and
Children and adolescents at risk for obesity, whose goal is weight maintenance, should
95th percentile should be monitored at least every 2 weeks during the weight loss phase and
Infants :
- Promote breastfeeding
consumption
- Decrease TV viewing
B. Nutritional Guidelines
- Increasing fruit, vegetable and whole grain consumption ( brown rice, wheat bread) while
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
For preschool and preadolescent children, Epstein et al (1990) have been used the
The glycemic 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 Children’s 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
Low Glycemic Index Foods Moderate Glycemic Index foods High Glycemic Index foods
(Score under 50) (Score 50-70) (Score >70)
Barley Sweet potato White bread
Grapefruit Whole wheat bread Rice cakes
Kidney beans, lentils Corn, popcorn French fries
Apple, pear, peach Brown rice, couscous Cornflackes
Orange, grape Whole wheat pita Baked white potato
Non fat plain yogurt Green pea soup Instant white rice
Low fat milk Apricot, mango Candy, regular soda
Whole grain pasta
(Copperman & Jacobson, 2004).
- The diet consists of caloric restriction between 600-900 calories per day, 1.5 to 2.5 grams
of high biological value protein per kilogram of weight per day and extremely limited
The use of Very Low carbohydrate, High-fat Ketogenic Diet that induces ketosis
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)
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
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.
- 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
20
minutes each day. Fast walking for 30 minutes each day or shorter or more intense
2004).
This will not be easy task, because there are a number of factors operating in the opposite
direction, including: motorization; restricting physical activities both for convenience and safety reasons;
pursuit of sedentary recreations during leisure time, such as computers, videogames, and television; and
easy access to high fat/sugar fast foods. Improving parents’ nutritional knowledge and awareness of the
risk of obesity through educational programs and counselling could be a way of achieving a useful
“immunization program”. However it’s essential that the entire society be changed to be more sensitive to
This presentation on weight management for children should be incomplete if it does not
consider the context of underweight in the double burden of malnutrition. There is also a need
for the 20 million children who are severely acutely malnourished and most of them living in
south Asia ( the Philippines being a part of that region) and in sub-Saharan Africa ( the
After a long experience of inpatient management program, it was found that in many poor
countries, the majority of children who have severe acute malnutrition are never brought to
health facilities. In these cases, only an approach with a strong community component can
provide them with the appropriate care. Evidence shows that about 80 per cent of children with
severe acute malnutrition who have been identified through active case finding, or through
treated at home. In response to this, the World Health Organization, the World Food Programme,
21
the United Nations System Standing Committee on Nutrition and the United Nations Children’s
Fund have come up with a joint statement on a new strategy named Community-based
Patients without an adequate appetite and/or a major medical complication are initially admitted
- During this phase patients are given a therapeutic milk formula called F-75(meaning 75
malnourished children).
Ingredient Amount
Water (boiled & cooled) 2 litres
WHO-ORS * 1 litre-packet
Sugar 50 g
Electrolyte/mineral solution 40 ml
During this phase the patients start to gain weight slowly as a fortified milk formula
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.
22
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
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
Plumpy Nut
Ingredients : Plumpy Nut is composed of peanut butter, vegetable fat, dry skimmed milk,
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).
- How to use it ?
2- BP-100™
- Ingredients of BP100: It is a solid F-100 with added iron, Wheat flour (backed)
Oat flour (backed), Vegetable oil, Sugar, Milk proteins, Skimmed milk powder
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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
BP100 (529.4 Kcal/100gr) and One bar of BP-100 (56.7gr) is 300 Kcal.
3- eeZeePaste NUT™
eeZeePaste NUT™ is a semi liquid ready to use therapeutic food (RUTF) of high nutritional
value, developed for use in the phase 2 of treatment (rehabilitation & treatment phase) of
-Nutritional qualities
The formulation of eeZeePaste NUT™ is based on the WHO F-100 formula. Its nutritional
specifications are similar to the F-100 milk, the only difference being that eeZeePaste NUT™
contains iron (10mg per 100g). One sachet of 92g contains 500 kcal.
Table 8. Distribution
Weight (kg) eeZeePaste NUT™ Sachets per day Sachets per week
3.0-5.0 2( 1000 Kcal) 14
5.0-10 4(2000 Kcal) 28
10-20 5(2500 Kcal) 40
20-40 7(3500Kcal) 50
>40 8(4000Kcal) 56
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
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
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
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Conclusion
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population.
30
31
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http://www.unicef.org/sowc09/statistics/tables.php
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33
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