Nutrition Management of Chronic Health Issues Overweight and Obesity

Appropriateness of weight status for teens is best assessed by calculating body mass index (BMI). BMI is a measure of a person’s weight (kg) divided by their height2 (m2). The Centers for Disease Control and Prevention BMI calculator is available online at http://nccd.cdc.gov/dnpabmi/Calculator. aspx. This is an accurate and quick way to calculate BMI values for youth. These values must be compared to age- and gender-appropriate percentiles to determine the appropriateness of weight status. Adolescents with a BMI greater than the 85th but lower than the 95th percentile are considered overweight while those with a BMI above the 95 th percentile are considered obese [31]. Growth curves based on BMI values for children and adolescents are available from the National Center for Health Statistics and should be incorporated into the medical records of all teens.

More than one-third of adolescents in the USA are overweight and one-fifth are obese [32]. There are dramatic differences by race and ethnicity (Table 4.1). A range of medical and psychosocial complications accompanies overweight among adolescents, including hypertension, dyslipidemia, insulin

Table 4.1 Prevalence of at-risk for overweight and overweight by race and gender among 12- to 19-year-olds in NHANES 2009-2010

Overweight

Obese

Males

White

32.2

17.5

Black

37.4

22.6

Hispanic

42.9

23.9

Male Total

34.6

19.6

Females

White

27.6

14.7

Black

45.1

24.8

Hispanic

41.9

19.8

Female Total

32.6

17.1

Source: All data taken from Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index in US children and adolescents, 1999-2010. JAMA 2012;307:483-90

Table 4.2 Recommended indices for common chronic health issues in adolescents

Acceptable

Borderline

Unacceptable

Total cholesterol (mg/dL)

<170 (<4.4 mmol/L)

170-199 (4.4-5.15 mmol/L)

>200 (>5.18 mmol/L)

Non-HDL cholesterol (mg/dL)

<120 (<3.11 mmol/L)

120-144 (3.11-3.73 mmol/L)

>145 (>3.76 mmol/L)

LDL cholesterol (mg/dL)

<110 (<2.85 mmol/L)

110-129 (2.85-3.34 mmol/L)

>130 (>3.37 mmol/L)

HDL cholesterol (mg/dL)

>45 (<1.17 mmol/L)

40-45 (1.04-1.17 mmol/L)

<40 (>1.04 mmol/L)

Triglycerides (mg/dL)

<90 (<2.33 mmol/L)

90-129 (2.33-3.34 mmol/L)

>130 (>3.37 mmol/L)

Apolipoprotein A-1 (mg/dL)

>120 (>1.2 g/L)

115-120 (1.15-1.2 g/L)

<115 (<1.15 g/L)

Apolipoprotein B (mg/dL) Hemoglobin (g/dL)

<90 (<0.9 g/L)

90-109 (0.9-1.09 g/L)

>110 (>1.1 g/L)

Males

>12.5 (12-15 years) (>125 g/L) >13.3 (16-18 years) (>133 g/L) >13.5 (>18 years) (>135 g/L)

Females

>11.8 (12-15 years) (>118 g/L) >12.0 (16+ years) (>120 g/L)

Hematocrit (%)

Males

>37.3 (12-15 years) >39.7 (16-18 years) >39.9 (> 18 years)

Females

>35.7 (12-15)

>35.9 (16-18 years)

Source: Based on: Bright futures nutrition. 3rd ed. Holt K, Wooldridge N, Story M, Sofka D, eds. Elk River, IL: American Academy of Pediatrics; 2011

resistance, type 2 diabetes mellitus, sleep apnea and other hypoventilation disorders, orthopedic problems, hepatic diseases, body image disturbances, and lowered self-esteem [33, 34]. Longitudinal studies of obesity and chronic disease risk among youth suggest an increased risk of morbidity and premature mortality from coronary heart disease, stroke, hypertension, diabetes, and asthma among adults who were overweight or obese during adolescence [34].

All adolescents should be screened for appropriateness of weight-for-height on a yearly basis, or more frequently if there are concerns about excessive weight gain (or loss). Teens with multiple risk factors for obesity require an in-depth medical assessment to diagnose potential comorbid complications [31]. Adolescents who are assessed as overweight should have their blood pressure and fasting lipid panels measured; those with a family history of premature cardiovascular disease or diabetes should also have AST, ALT, and fasting glucose levels measured [35]. All teens found to be obese

Table 4.3 Assessment and screening recommendations for health promotion among adolescents

Health concern

Screening and assessment recommendation

Anthropometric

measurements

  • • Measure and plot height, weight, and BMI
  • • Review weight status with teen and family.
  • • Overweight teens: Provide Step 1 counseling or refer to a registered dietitian/ nutritionist for weight management counseling; schedule follow-up appointment.
  • • Obese adolescents: Refer to a comprehensive weight management program for Step 2 counseling.

Family history of premature cardiovascular disease, diabetes, or obesity

• Assess for risk factors for chronic health conditions (hypertension, hyperlipidemia, diabetes) based on family history and weight status as necessary.

Blood pressure

  • • Review blood pressure with teen and family.
  • • In presence of elevated blood pressure, counsel adolescents and caregivers to follow DASH dietary pattern based on energy needs to achieve ideal body weight.
  • • Assess changes in blood pressure at follow-up and institute management with medication as needed, if dietary changes have not been successful.
  • • Refer overweight and obese adolescents to appropriate weight management program.

Blood lipids

Dietary intake and eating behaviors

  • • Review blood lipid indices with teen and family.
  • • Order blood lipid panel for overweight or obese adolescents.
  • • Overweight adolescents: Provide counseling regarding DASH diet based on energy needs to achieve ideal body weight or refer to a registered dietitian/nutritionist for medical nutrition therapy.
  • • Obese adolescents: Refer to a comprehensive weight management program.
  • • Up to 2 g/day of plant sterols or stanols can be recommended for use by adolescents.
  • • Manage dyslipidemia with medication if dietary changes and weight loss are not effective.
  • • Assess usual food intake using 24-h recall or 3- to 7-days food diary.
  • • Provide appropriate nutrition counseling or refer to a registered dietitian/nutritionist for medical nutrition therapy as needed.

Physical activity and sedentary activity

  • — Review usual daily physical and sedentary behavior patterns.
  • — Discuss recommendation for at least 60 min/day of moderate-to-vigorous physical activity.
  • — Emphasize importance of limiting sedentary activity, with no more than 2 h/day of screen time

Diabetes

  • — Assess for family history of diabetes, presence of acanthosis nigricans, and symptoms consistent with diabetes among overweight or obese adolescents.
  • — Review fasting blood glucose levels with teens and caregivers or refer to primary care provider for treatment and measurement of a fasting blood glucose level if laboratory data are not available.
  • — Provide medical nutrition therapy and nutrition counseling as appropriate.
  • — Refer overweight and obese teens to a comprehensive weight management program.

Adapted from: U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. Summary report. NIH Publication No 12-7486A, October 2012. Available at http://www.cdc.gov/diabetes/ pubs/pdf/ndfs_2011.pdf. Last accessed February 1, 2016

should have the previously mentioned laboratory values measured with the addition of microalbumin. Table 4.2 lists cut-points for common indices of chronic disease, while Table 4.3 provides an overview of assessment and referral recommendations based on an adolescent’s personal risk factors.

Treatment for overweight and obesity among adolescents is based on the degree of excessive body fat and the presence of comorbid health conditions [35]. Overweight teens with no personal risk factors or significant family history should follow Step 1 treatment guidelines which includes advice to:

  • • Consume five or more servings of fruits and vegetables each day (excluding French fries and other fried potato products)
  • • Remove sugar-sweetened beverages from the diet including soft drinks, sports drinks, energy drinks, fruit drinks, lemonade, and fruit punch
  • • Limit fruit juice to 6 oz. (180 mL) per day or less and only consume 100% fruit juice
  • • Participate in 60 min of moderate to vigorous physical activity, which can be done in four to six 10-15 min intervals or in 1 or 2 longer intervals. Teens should be able to carry on a conversation but not sing when they are participating at an appropriate level of intensity.
  • • Limit discretionary screen time to 2 h/day or less
  • • Limit intake of fast foods, convenience foods, and foods with added fats and/or sugars.

If Step 1 has not resulted in weight maintenance or modest weight loss within 2-3 months, teens should move on to Step 2 treatment. All overweight adolescents with personal risk factors should begin treatment at Step 2 as should all obese teens. Recommendations for Step 2 include all of those in Step 1 plus:

  • • Limit discretionary screen time to 1 h/day rather than 2 h/day
  • • Introduce a structured meal plan of 1400-1800 kcal/day that follows DASH dietary guidelines (see Table 4.4)
  • • Monitor daily food intake and physical activity to assure that adolescents are meeting their goals.

Step 2 should be implemented for 6-8 weeks to determine if weight is maintained or modest weight loss has occurred. If necessary, teens should move to Step 3 (as should all obese teens who have significant risk factors), which includes all recommendations from Step 2 plus:

• Weekly visits for at last 8-12 weeks that include structured behavior modification techniques; more frequent contact may be desired or required by some teens and their families.

Table 4.4 DASH Eating plan to reduce hypertension and other chronic diseases: servings per day by food group and total energy intake

Food group

Serving size

1400 kcal

1600 kcal

1800 kcal

2000 kcal

Grains (with whole grains the majority of choices)

  • 1 slice bread
  • 1 oz. (28 g) dry cereal
  • 1/2 C (0.12 L) cooked rice, pasta, or cereal

6

6

6

6-8

Vegetables

  • 1 C (0.24 L) raw leafy greens
  • 1/2 C (0.12 L) raw or cooked vegetable
  • 1/2 C (0.12 L) vegetable juice

3-4

3-4

4-5

4-5

Fruits

1 medium fruit, 1/4 C (0.06 L) dried fruit 1/2 C (0.12 L) fresh, frozen, or canned fruit 1/2 C (0.12 L) fruit juice

4

4

4-5

4-5

Milk and milk

products (fat-free or low-fat choices) or substitutes

  • 1 C (0.24 L) milk or yogurt 1 C (0.24 L) soy, almond, rice, or other milk substitute
  • 1.5 oz. (42 g) cheese

2-3

2-3

2-3

2-3

Lean meats, poultry, or fish

1 oz. (28 g) cooked meats, poultry, or fish 1 egg

3-4

3-4

<6

<6

Nuts, seed, and legumes

1/3 C (0.08 L) or 1.5 oz. nuts 2 Tb (30 mL) peanut or other nut butter 2 Tb (30 mL) or 0.5 oz. (14 g) seed 1/2 C (0.12 L) cooked legumes

3/week

3-4/week

4/week

4-5/weeks

Fats and oils

  • 1 tsp. (5 mL) margarine 1 tsp. (5 mL) vegetable oil
  • 1 Tb (15 mL) mayonnaise
  • 2 Tb (30 mL) salad dressing

1

2

2-3

2-3

Sweets and added

1 Tb (15 mL) sugar

<3 oz./

<3 oz./

<5 oz./

<5 oz./

sugars

1 Tb (15 mL) jelly or jam 1/2 C (0.12 L) sorbet or gelatin 1 C (0.24 L) lemonade

week

week

week

week

Source: Based on the U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. Summary report. NIH Publication No 12-7486A, October 2012. Available at http://www.cdc.gov/dia- betes/pubs/pdf/ndfs_2011.pdf. Last accessed February 1, 2016

  • • Supervised physical activity may be provided to assure that teens are safely able to exercise vigorously.
  • • Mental health screening with referral for depression or other identified issues.
  • • Further structure to meal plans or reduction to 1400 kcal/day may be required; teens should be monitored weekly when on low-calorie diets.

Step 4 treatment is implemented when Step 3 is not effective or for significantly obese teens who have comorbid conditions that require intensive intervention. This level of care is provided only in a tertiary care center that specializes in pediatric obesity and may include medication management, meal replacement, very-low-calorie or protein-sparing-modified fast diets, or bariatric surgery.

 
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