Presented by Erica Timmermann Dietetic Intern 2009 NTR 622 Case Study Seminar Julie Moreschi Spring 2009 Childhood Obesity Obesity among children and adolescents is on the rise today and is a major health concern ID: 813174
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Slide1
Childhood Obesity: More Than Just BMI
Presented by: Erica Timmermann
Dietetic Intern 2009
NTR 622
Case Study
Seminar
Julie
Moreschi
Spring 2009
Slide2Childhood Obesity
Obesity among children and adolescents is on the rise today and is a major health concern.
According to the NHANES survey from 1976-1980 and 2003-2006 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:
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/prevalence.htm
.
Assessed April 3
rd
2009, 2009.
Slide3Illinois 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:
http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=507&loc=IL&year=2007
. Assessed April 3
rd
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:
http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=506&loc=IL&yeay=2007
. Assessed April 3
rd
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:
http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=507&loc=CH&yeye=2007
. Assessed April 3
rd
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:
http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=506&loc=CH&yeye=2007
. Assessed April 3
rd
2009, 2009.
Slide4Childhood 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:
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/defining.htm
. Accessed April 5th 2009
Slide5Pathophysiology
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
http://emedicine.medscape.com/article/985333-overview
Accessed April 5th 2009.
Slide6In 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
http://emedicine.medscape.com/article/985333-overview
Accessed April 5th 2009.
Slide7Ghrelin 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:
http://en.wikipedia.org/wiki/Ghrelin
. Accessed May 2nd.
[9] Wikipedia; the free encyclopedia:
Leptin. Available at website: http://en.wikipedia.org/wiki/Leptin. Accessed May 2nd 2009.Adopted from Deepa Handu. Professors at BenU. Obesity Theory and Practice Application. Lecture 5: Childhood Obesity.
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:
http://en.wikipedia.org/wiki/Ghrelin
. Accessed May 2nd.
[9] Wikipedia; the free encyclopedia: Leptin. Available at website:
http://en.wikipedia.org/wiki/Leptin
. Accessed May 2nd 2009
.
Adopted
from
Deepa Handu. Professors at BenU. Obesity Theory and Practice Application. Lecture 5: Childhood Obesity.
Slide9However, 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 http://emedicine.medscape.com/article/985333-overview
Accessed April 5th 2009.
Slide10Contributing 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.
Slide11American 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
https://www.adaevidencelibrary.com/topic.cfm?cat=2792
[10] American Dietetic Association: Evidenced based library. Factors associated with childhood overweight. Available at website:
https://www.adaevidencelibrary.com/topic.cfm?cat=2792
. Accessed April 5
th
2009
Slide12C.W
.
Slide13Patient 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 3
rd
grade.
He has two older female siblings and two parents that have been divorced for four years now.
Slide14Living 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.
Slide15Patient Profile: CW
Past Medical History:
Attention
Deficient Disorder (
ADD
)
D
iagnosed
two years ago. Current Symptoms: Excessive thirst Excessive hunger Inability to pay attentionTirednessS
leep 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
.
Slide16Diabetes 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
http://emedicine.medscape.com/article/985333-overview
Accessed April 5th 2009.
Slide17Risk 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.
Slide18Weight History
CW has been overweight since birth tipping the charts at the 90th
to
95
th
percentile.
Since
his parents divorce when he was 4, his eating habits have only gone down hill and have become increasing worse.
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):145-163.
Slide20Parent 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. 1999 Jun;103(6):85.
Slide21Parents 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.
Slide22Nutritional Data
Height: 5’0 feet
Above the 97
th
percentile for stature-for-age
Weight:
158
pounds
Above the 97th percentile for weight-for-ageTaken at doctors office at the end of FebruaryBMI: 30.8Above the 97th percentile for BMI-for-ageUBW:
Varies since he is a child.
Gaining 1-2 pounds/month
Slide23Medications
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
[13]
Pronsky
ZM.
Food Medication Interactions
, 14
th
ed.
Birchrunville
, PA: Food-Medications Interactions; 2006.
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
2/20/09
93 mg/
dL
NormalTotal Cholesterol< 120-199 mg/dL2/20/09156 mg/dLNormalLDL
< 100
2/20/09
80 mg/
dL
Normal
HDL
> 40
2/20/09
43 mg/
dL
Normal
Slide25Typical Day for C.W.
Breakfast
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.
Slide26Nutrient Analysis of a Typical Day
Based on the nutrient analysis:
Total caloric intake: 3400
kcals
Protein: 97.91 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 servings9 from simple carbohydratesProtein: 11%. 5.0 servings of lean protein sourcesFat: 38% 23 servings Fruit: 3.5 servings
Vegetables: 3 servings
Milk: 1 servings
Slide27Personnel 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
Slide28Personnel 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.
Slide29Personnel 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.
Slide30Personnel 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.
Slide31Current Diet Order
After meeting with the RD on March 2nd
2009, she prescribed the follow diet:
1800-2000 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.
Slide32Diet Recommendations
Education: 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 dayPhysical activity: 60 minutes per day
Slide331800 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 = 112.5 grams /7= 16 servings
5 servings from lean meats
Slide34Diet 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
https://www.adaevidencelibrary.com/topic.cfm?cat=2795
[14] American Dietetic Associations Nutrition Care Manual. Treating childhood overweight. Available at website:
https://www.adaevidencelibrary.com/topic.cfm?cat=2795
. Accessed April 4
th
2009
Slide35Dietary Interventions
Dietary Interventions include the use of:
1) Balanced macronutrient diets
1)By age Groups
2)Selected Diets
2) Altered macronutrient diets
Slide36Balanced 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:
http://www.adaevidencelibrary.com/topic.cfm?cat=2939
.
Accessed April 4
th
2009.
Selected Diet Approaches
Stop Light Diet
2) Food Guide Pyramid
Slide38Stop
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;105:44-51.
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;105:44-51.
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:
http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=250051
.
Accessed April 4
th
2009
Altered Macronutrient Diets
Low FatAltered Carbohydrates
Altered Protein
[14] American Dietetic Associations Nutrition Care Manual. Treating childhood overweight. Available at website:
https://www.adaevidencelibrary.com/topic.cfm?cat=2795
. Accessed April 4
th
2009
Slide42Physical 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:
http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=105
.
Accessed April 5
th
2009
Slide43Treatment 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:
http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=99
Accessed April 5
th
2009.
Slide44Treatment 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:
http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=97
. Accessed April 5
th
2009.
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; 9:235-240. [22] Ritchie LD, Welk G,
Styne
D, Gerstein D, Crawford P. Family environment and pediatric overweight
Slide46Other 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.
Slide47Sample 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 meat1 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 vegetables1 small salad with lettuce tomatoes, onions, and cucumbers2 tbsp of low fat salad dressing1 tsp margarineSnack 1 cup of skim milk3 graham cracker squares
½ cup of unsweetened applesauce
Slide48Short 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
Slide49Long Term Goals for C.W. and Parents
Weight MaintenanceImproved 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.
Slide50ADIME 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 97
th 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.
Slide51ADIME: 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.
Slide52ADIME: 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
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.
Slide54Certificate Opportunity
June 15-17, 2009Certificate 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:
http://www.cdrnet.org/wtmgmt/childhood.htm
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:
http://www.cdrnet.org/wtmgmt/certificateoftraining.htm
Slide55THANK YOU!
Sincerely,
Erica Timmermann
Slide56References
[1] Centers for Disease Control and Prevention. Overweight prevalence. Available at website:
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/prevalence.htm
.
Assessed April 3
rd
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:
http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=507&loc=IL&year=2007
. 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:
http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=506&loc=IL&yeay=2007
. Assessed April 3
rd
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: http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=507&loc=CH&yeye=2007. 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:
http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?ByVar=CI&cat=5&quest=506&loc=CH&yeye=2007
. Assessed April 3
rd
2009, 2009.
[6] Centers for Disease Control and Prevention. Defining childhood overweight and obesity. Available at website:
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/defining.htm
. Accessed April 5th 2009
[7] Schwarz SM.
Emedicine
from WebMD. Obesity. Available at
http://emedicine.medscape.com/article/985333-overview
Accessed April 5th 2009.
Slide57References
[8] Wikipedia: the free encyclopedia:
Ghrelin
. Available at website:
http://en.wikipedia.org/wiki/Ghrelin
. Accessed May 2nd.
[9] Wikipedia; the free encyclopedia:
Leptin
. Available at website:
http://en.wikipedia.org/wiki/Leptin. Accessed May 2nd 2009. [10] American Dietetic Association: Evidenced based library. Factors associated with childhood overweight. Available at website: https://www.adaevidencelibrary.com/topic.cfm?cat=2792. Accessed April 5
th
2009.
[11] Gerald LB, Anderson A, Johnson GD, Hoff C, Trimm RF. Social class, social support and obesity risk in children.
Pediatrics.
2006; 20(3):145-163.
[12] Strauss RS, Knight J. Influence of the home environment on the development of obesity in
children.
Pediatrics
. 1999 Jun;103(6):85. [13] Pronsky ZM. Food Medication Interactions, 14th ed. Birchrunville, PA: Food-Medications Interactions; 2006. [14] American Dietetic Associations Nutrition Care Manual. Treating childhood overweight. Available at website:
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