obesity Flashcards
- AAP reaffirms its recommendation of exclusive breastfeeding for how long?
- It is followed by breastfeeding in combination with introduction of complementary foods until at least what age?
- first 6 months
- 12 months
breastfeeding advantages
- emotional connection between mom and baby
- Protective effect against rsp illnesses, ear infections, GI dz, and allergies (asthma, eczema and atopic dermatitis)
- Reduces risk of SIDS (by over ⅓)
- decr obesity
- decr risk for mother for postpartum hemorrhage, longer amenorrhea, ovarian and premenopausal breast CA and possibly reduced risk of osteoporosis
Breastfeeding Disadvantages
- Maternal fatigue
- Medications that mother may not be able to take due to breastfeeding
- Special dietary issues
- Latching issues / pain
- Avoid in alcoholic mother or drug abuse
- Vit D_ supplementation
How Often and How Much Should Your Baby Eat?
Babies should be fed whenever they seem hungry.
How do I know when the baby is hungry?
Hunger cues
- will cry MC
- best to watch for hunger cues before the baby starts crying, which is a late sign of hunger and can make it hard for them to settle down and eat.
name some hunger cues
- Licking lips
- Sticking tongue out
- Rooting (moving jaw and mouth or head in search of breast)
- Putting his/her hand to mouth repeatedly
- Opening her mouth
- Fussiness
- Sucking on everything around
T/F: every time the baby cries or sucks it is always because they are hungry
F - Not always; Babies suck not only for hunger, but also for comfort
Most newborns eat every ___ to ____ hours, or ___ to ____ times every 24 hours.
- 2 to 3 hours
- 8 to 12
At about 2 months of age, babies usually take ? ounces per feeding every ? hours.
2 to 4
3 to 4
At 4 months, babies usually take ? ounces per feeding.
4 to 6
At 6 months, babies may be taking up to ? ounces every ? hours.
8
4 to 5
Most babies will increase the amount of formula they drink by an average of ? ounce each month before leveling off at about ? ounces per feeding.
1
7 to 8
Overfed babies can have what s/s?
what are they at higher risk for in later life?
stomach pains, gas, spit up or vomit and be at higher risk for obesity later in life
T/F: It’s better to offer less feeding to the baby
T
- Babies are usually pretty good at eating the right amount. Infants who are bottle feeding may be more likely to overfeed
- since you can always give more if your baby wants it. This also gives babies time to realize when they’re full.
what is a good indicator of whether he or she is getting enough to eat?
newborn’s diaper
In the first few days after birth, a baby should have ? wet diapers each day. After the first 4 to 5 days, a baby should have at least ? wet diapers a day.
2 to 3
5 to 6
if babies stay in healthy growth percentile ranges, what does that indicate about the amount of food theyre getting during feedings?
they are probably getting a healthy amount of food during feedings.
- The current AAP recommendation is that all infants and children should have a minimum intake of ? of vitamin D per day beginning soon after birth.
- How long should babies be on this regimen until?
- 400 IU
- should continue until they are weaned to at least 1 qt (1 L) of whole milk per day (Whole milk should not be used until after 12 months of age).
babies on formula do NOT need vitamin D supp if they are drinking at least how muc formula?
- 32 ounces
- All formula has at least 400 IU/L of vitamin D already
- Whole milk should not be used until after 12 months of age
recommendations for iron supp in breastfed babies
1 mg/kg/day of a liquid iron supplement until iron-containing solid foods are introduced at about six months of age.
iron supp recommendations for formula fed babies
use iron-fortified formula (containing from 4 to 12 mg of iron) from birth - first year of life.
Infants will lose up to ?% of their birth weight, which should be regained by ? days
7
10-14
Follow-up newborn visit or weight check should be performed in office ? days after birth
3-5
Infants must gain ? grams per day (100 - 120 cal / kg / day needed)
15
what is not needed for formula fed babies compared to breastfed babies?
No other vitamin or mineral supplement is needed
No food products, only formula until ? months.
why?
- 4 months
- Oropharyngeal coordination is immature before 3 months of age, too early to introduce solid foods
how to introduce food products afte baby is 4 months old?
- Start single grain rice cereal at 4 months of age, in a spoon, twice daily
- If tolerated can progress to mixed cereals later weeks (oat, corn, wheat and soy)
- Baby foods at 6 months - fruits and veggies, new food every 3-4 days
- No meats until 9 months
4 signs of Readiness for Complementary foods:
- Able to hold head up
- Able to sit unassisted
- Brings objects to mouth showing interest in foods
- Ability to track spoon and open the mouth
what commen allergenic foods should be introduced when other complementary foods are introduced
peanuts, egg, cow milk products, tree nuts, wheat, crustacean shellfish, fish, and soy
- peanut-containing foods in 1st yr reduces the risk of a food allergy to peanuts.
- Cow milk, as a beverage, should be introduced at >12 months
earliest age of peanut introduction in severe eczema, egg allergy, or both?
4-6 months
earliest age of peanut introduction in mild-moderate eczema?
~6 months
earliest age of peanut introduction if no eczema or any food allergy?
age appropriate and in accordance w/ family and culture
In toddlers - Milk consumption limited to ? oz per day
16
when can you introduce skin or 2% milk?
> 2 y/o
how many meals for a child age 2 y/o?
three healthy meals plus two snacks a day
toddlers will have a sharp drop in appetite when?
after 1st bday - growth rate has slowed, and really doesn’t require as much food now.
what age for 1/2 of flintstone vitamin?
18 months
healthy habits to keep in mind for child nutrition
- children responsible for deciding what and how much they want to eat from what they are offered
- do not reward w/ food
- do not eat and watch TV
recommendations for carbohydrate intake in child nutrition
- 55 - 60% of daily calories
- ½ of all grains should be whole grains
- High fiber foods
recommendations for fat intake in child nutrition
- < 30% of total calories
- Saturated and polyunsaturated fats = < 10% total calories each
what food intake do we need to Limit by restricting processed food
sodium
What Snacks Toddlers Should Avoid:
Big chunks of any food in < 4y/o - choking hazards
Heavily processed foods
Each day, a child between ages 1 and 3 years needs about ? calories for every inch of height.
40
The child’s serving size should be approximately how much?
one-quarter of an adult’s
Feeding & Nutrition Tips for 1-to 3-Year-Olds
- Accept strong preferences about foods. Your three-year-old may be enthusiastic about eating, but he or she may have very specific food preferences.
- Encourage, but don’t force trying new foods. Offer very small amounts of a new food for your child to taste
- Offer nutritious food choices at every meal.
- Meals can be simple and nutritious. Remember, meals at this age don’t need to be fancy
- Turn off TV—esp at mealtimes.
Feeding & Nutrition Tips for 4-to 5-Year-Olds
- Offer a range of healthy foods.
- Don’t expect children to “clean their plates.
- Offer regular meal times and sit together.
- Limit processed food and sugary drinks.
- The best drinks are water and milk.
- Small portions for small children
- Turn off TV
- Teach table manners
calorie requirements for 2-3 y/o
1k
calorie requirements for 4-8 y/o
1.4k
calorie requirement for 9-13 y/o females
1.6k
calorie requirement for 9-13 y/o males
1.8 k
calorie requirement for 14-18 y/o females
1.8 k
calorie requirement for 14-18 y/o male
2.2k
majority of today’s children will have obesity at age ?
35
RF for childhood obesity
- Family History
- Infants with diabetic mothers
- Reduction in mandatory PE in school
- Processed foods
- Fast foods
- Increase in sedentary lifestyle
- Later bedtime
- Ghrelin / leptin hormone pathway dysfunction
- If 1 parent is obese - ? times incr risk of obesity in adulthood for their child.
- What if both parents are obese?
3
15 fold
what hormone is a mediator of long-term regulation of energy balance, suppressing food intake and thereby inducing weight loss
leptin
a fast-acting hormone, seemingly playing a role in meal initiation
Ghrelin
why do obese patients have more leptin and less ghrelin levels but still do not lose weight?
Theory - body less sensitive to them and “out of whack” causing disruption in the system, just like insulin resistance
Leptin increased in adipose tissue, instead of making you less hungry there is likely leptin resistance.
Giving someone more leptin does not work to help fight obesity if the levels are already high (just like giving serotonin does not work on a person who is NOT depressed…their levels are already high). It would only work in someone with LOW leptin levels
Medications Associated with Obesity
- Glucocorticoids / cortisol
- Megace - appetite stimulant
- Sulfonylureas - antidiabetic
- TCAs
- MAOIs
- OCs
- Insulin (excess doses)
- TZD - antidiabetic
- Risperidone (Risperdal) - antipsychotic
- Clozapine - antipsychotic
what hormones incr in obese?
- Leptin
- estrogen
- cortisol
- testosterone (women only)
what hormones decr in obesity?
- growth hormone
- testosterone (men only)
- What hormone stores energy and is made by fat cells?
- which hormone is the main production in fat cells?
- Leptin
- Estrogen
Organ Systems Affected by childhood obesity
- Cardiovascular
- Respiratory
- Orthopedic
- GI / GU
- Psychosocial
- Growth
- CNS
- Skin
how to dx childhood obesity
- BMI chart
- Obtain history regarding diet and exercise
- Physical examination
- Lab studies
Obesity Classifications based on BMI (percentiles)
- < 5th percentile - underweight
- 5-84th percentile - healthy wt
- 85-95th percentile - overweight
- 96-99th percentile - obesity
- > 99th percentile - severe obesity
ROS findings in EENT in childhood obesity?
snoring
ROS findings in GI in childhood obesity?
- Dyspepsia
- Constipation
- Abd Pain - Gallbladder; Fatty liver
ROS findings in GU in childhood obesity?
- Polyuria
- Vaginal discharge
- Vaginal itching
- Difficulty urinating or abnl stream
- Menstrual irregularity
ROS findings in endocrine in childhood obesity
Polyuria
Polydipsia
ROS - neuro findings in childhood obesity
- HA
- Blurred vision
ROS - psych findings in childhood obesity
- Depression
- Anxiety
- Bullying
ROS - skin findings in childhood obesity
- Rash
- Hirsutism
- Acne
what MS finding can be seen in childhood obesity?
ROS
joint pain
PE for childhood obesity
- VS/Growth chart - BP, short stature
- EENT - papilledema, CNVI paralysis, tonsillar hypertrophy
- Abd - tenderness, hepatic hypertrophy
- GU - micropenis, hypogonadism, hidden penis
- MS - small hands, polydactyl, pain
- skin - acne, hirsutism, acanthosis nigricans, skin tags
provider barriers when diagnosing childhood obesity
- Time constraints
- Futility of tx efforts
- Lack of knowledge regarding current recommendations
- Reluctance to discuss weight-related issues
- Lack of patient and parental motivation
- Lack of access to BMI charts
Findings from a Qualitative survey of communication barriers between providers and parents of overweight children:
- It was difficult to initiate a discussion of weight issues
- Growth charts were an essential tool to start conversations about overweight or obesity
- Denial, defensiveness, and excuses were common reactions among parents
- Weight-related conversations were especially difficult if the parents were
what words to avoid when approaching childhood obesity topic?
- Avoid - obese, thick, fat, overweight
- Instead use - excess weight, elevated BMI leads to increased risk factors for certain morbidities
- Decr BMI is enough to decr CV risk and future risk
labs for childhood obesity
- CBC
- Complete Metabolic Panel (with fasting glucose)
- Insulin Level
- TSH
- HbA1C
- Urinalysis
- Vitamin D
- Lipid Panel
AAP recommends all children between 9-11 y/o screened for ? due to the growing epidemic of obesity in children
high blood cholesterol levels
Secondary recommendations for the following with the first level after 2 yrs of age but no later than 10 yrs of age:
- Any child whose parents or grandparents have had heart attacks, blocked arteries or any blood vessel disease (such as stroke), at age < 55 in men, or < 65 in women
- Any child whose parents or grandparents have total blood cholesterol levels of >240 mg/dL
- Any child whose background hx is unknown, or have heart dz, DM, high BP, smoke or are obese
mgmt for childhood obesity
- Dietary modifications
- Sleep modifications
- Exercise modifications
- Accountability
- Treat underlying disorders
diet modifications in childhood obesity
- 5 fruits and vegetables per day (portion plates)
- **Make it fun **
- Eat breakfast every day (yogurt, milk, cheese)
- Regularly enjoy meals as a family
- Limit fast food / remove soda pop
- Use fruits and vegetables as a snack (when shopping, start in the area where they keep fruits and veggies)
- Try out child friendly vegetarian foods
- TV OFF -100 more cal consumed when tv on, even in background!
- NO juice - Water, milk; Crystal Light, tea, etc. 1-2x a week as a snack
- NO diet drinks - incr fasting glucose and insulin levels, incr snacking and hunger
- Slow down
- Breakfast and protein
an essential part of a well-balanced diet and critical for your child’s growth and brain development. So, instead of trying to cut out fat from your child’s diet,
fat
Focus on replacing unhealthy fats with with healthy fats.
Why shouldn’t a Preschoolers’ Diets Be Fat-Free?
- may actually promote unhealthy wt gain—esp if dietary fats are replaced with added sugars.
- no link between the overall percentage of calories from fat and any important health outcome, including cancer, heart disease, and weight gain.
more important to focus on eating beneficial “good” fats and avoiding harmful “bad” fats. Fat is an important part of a healthy diet.
what type of fat has lower disease risk?
what foods have this fat?
- Monounsaturated and polyunsaturated fats
- vegetable oils (such as olive, canola, sunflower, soy, and corn), nuts, seeds, fish.
what type of fat increases disease risk, even when eaten in small quantities.
trans fat
Four Golden Rules of Eating
- Divide Responsibilities. Parent’s job to purchase healthy, child’s job to choose what and how much to eat of the food offered.
- Eat when your body is hungry. Stop when your body is full.
- Don’t make children “clean the plate”. Don’t reward children for finishing their dinner with more food. Use smaller portions.
- Eat together. Most potent education comes from modeling our habits and behaviors we think are most important. Do not cook special food for your children. Involve them in meal preparation, eat the same foods, and share your love of eating.
sleep modifications in childhood obesity
- Lack of sleep shown to incr ghrelin levels (appetite stimulant)
- Lack of sleep shown to decr leptin levels (appetite suppressant)
- Lack of sleep incr evening cortisol levels, leading to insulin resistance
- For every hour less sleep per night (of the age recommendation), there is an increase risk of obesity
- Most pediatric obesity specialists believe this is even more important than exercise!
- NO TV in child’s bedroom
recommended sleep hours per 24 hr period in pediatric populations?
- infants (4-12m) - 12-16 hrs (including naps)
- toddlers (1-2y) - 11-14 hrs (including naps)
- preschoolers (3-5y) - 10-13 hrs (including naps)
- gradeschoolers (6-12y) - 9-12 hrs
- Teens (>13y) - 8-10 hrs
exercise modifications in childhood obesity
- Not much of a change if exercise initiated without dietary modification
- Join a sporting activity
- Exercise together (play a game of tag, go on a walking scavenger hunt, exercise to online videos, Zumba, Wii)
- Limit TV / electronics time to < 2 hours per day, and ideally < 1 hour per day
- Do not underestimate adolescents and their tech devices - Pedometers work; Apps for iPhones
mental health mgmt in childhood obesity
- Increased stress; Increased cortisol - increased fat
- Obesity is the #1 reason for bullying at school
- Increased depression and anxiety
- R/o bulimia
- 50% of women who are obese in adult bariatric centers have hx of sexual assault
- Suicide attempts
what medications for wt loss in children?
- Topiramate (Topamax) - not FDA approved for this but has been used
-
Phentermine - controlled substance
- Appetite suppressant for short term use
- Irregular HR, psychosis, panic, HF
- Not FDA approved -
Qsymia (Topiramate / Phentermine combo) - approved by FDA for obesity treatment
- Specific BMI indications
- NOT FDA approved in children, but has been used - Treat other underlying diseases - Metformin, Lisinopril, etc.
surgical options in childhood obesity
- Most bariatric procedures have the following stipulations:
- ≥ 15 y/o
= BMI > 40 kg/㎡ or weight exceeding 100% of ideal body weight (IBW) - Gastric bypass (MC) - Vertical banded gastroplasty (VBG)
- Laparoscopic adjustable gastric banding (LAGB) - Safer; Reversible
- considerations if obese and have Vit D deficiency?
- mgmt if level 20-29?
- what if < 20?
- Not outside playing in sun; Need more milk, mushrooms, fatty fish; Associated w/ incr fasting insulin levels
- Normal amount of Vit D is 600 U/d
- level 20-29 - Vit D3 OTC - 1000 U/d; Recheck q 3 mos
- level < 20 - Vit D2 (Rx) - 50,000 U/wk; Recheck q 3 mos, if nml follow above protocol
12% of females with obesity
Hirsutism, acne, oliguria
Elevated free testosterone
what other dx?
PCOS
- Although tall and lean as adults, may be tall and obese as adolescent
- Hypogonadism
- Decreased free testosterone
what other condition?
Klinefelter Syndrome
3 other conditions to consider in childhood obesity
- PCOS
- klinefelter syndrome
- metabolic syndrome
criteria for metabolic syndrome
Meets 3 out of 5 criteria
- Abdominal Obesity - waist circumference (WC) - ≥ 90th percentile
- Hypertriglyceridemia - ≥ 110
- Abnormal cholesterol and HDL - HDL ≤ 40
- HTN - ≥ 90th percentile
- Impaired glucose tolerance or fasting glucose - ≥ 110
- MC syndromic form of obesity
- Loss of paternally expressed genes (chromosome 15q)
- Early mortality
- Hyperphagia with progressive obesity
- Short stature and growth hormone deficiency
- Survival >50 years old rare due to issues with obesity
- Resistant to diet and exercise
dx?
Prader - Willi Syndrome
major criteria for Prader - Willi Syndrome
1 point each
- Hypotonia
- Feeding issues
- Excessive weight gain
- Hypogonadism
- Facial anomalies
- Developmental delay
- Hyperphagia
minor criter for Prader - Willi Syndrome
½ point each
- Decreased fetal movement
- Behavior issues
- Sleep disturbance or apnea
- Short stature
- Hypopigmentation
- Small hands / feet
- Narrow hands with straight ulnar border
- Eye abnormalities (esotropia, myopia)
- Thick, viscous saliva with crusting corners
- Speech issues
- Skin picking
f/u for pediatric obesity
- q1-3 months - BMI, VS, goals/target
- 3-6 months & no change - refer (wt loss specialist, dietitian)
