NDD10603

NDD 10603
LECTURE 7: CHILD AND
PREADOLESCENT NUTRITION
DR. SHARIFAH WAJIHAH WAFA BTE SST WAFA
School of Nutrition and Dietetics
Faculty of Health Sciences
sharifahwajihah@unisza.edu.my
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 Outline
1. Introduction
– Growth and development
– Physiological development
– Cognitive development
2. Eating behaviour
3. Energy and Nutrient Needs
4. Common Nutrition Problem
5. 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

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

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

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
SessionsCompleted(%)
* 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
0
Masa (bulan)
Mengurangkan tingkahlaku sedentari
Perubahnperatusanberlebihan
beratbadan
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-month
intervention
Control
Perubahan menonton TV
(jam/minggu)
P<0.001
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
6-month
intervention
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 POINTS
1. 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

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