Children overweight management & malnutrition+disordered eating

How to assess child’s growth?

WHO growth standards depict a rate of growth that serves as a goal or standard for all healthy infants and children.

2 studies: WHO Growth standard (birth - 5 yrs) and WHO growth references (5-19 yrs)

WHO Growth Standards

Based on Multicentre Growth Reference study from 6 different countries with children living in conditions favourable to grow. All children in the sample were exclusively or predominantly breastfed for the first 4-6 months of life, with breastfeeding continuing for at least 12 months.

Were developed to reflect how children should grow.

Key finding: minimal differences in growth patterns among 6 ethnically diverse communities included in the study.

Considered to be applicable worldwide and are recommended for use in Canada.

Key differences from CDC growth charts

CDC charts were only based on American sample.

CDC charts were only based on cross-sectional data while WHO charts are based on 24 month longitudinal study

CDC charts are based on a predominantly non-breastfed population (which grow faster after 6mo compared to breastfed grow faster in first 6mo).

CDC charts describe how their sample grew, regardless of whether it was optimal or not (had no inclusion/exclusion criteria). WHO growth standards depict a rate of growth that serves as a goal or standard for all healthy infants & children.

WHO Growth References (5-19 yrs)

Developed to help address widespread increase in childhood obesity. Has no cut offs, more following a curve.

Used the original sample size (in growth standard charts) supplemented with other data and statistical methods.

Adjustments were made for smoother transitions btwn growth standards and growth references AND for adult BMI cut-offs.

Breast fed vs bottle fed

Breastfed infants tend to grow faster in the first 6 mo (which leads to better development) and slower in the second 6 mo compared to bottle-fed infants.

Breast milk is also easier for infants to digest.

3 theories for feeding strategies vs overweight risk later in life

1. Gut microbiome. Breast milk contains probiotics (healthy, live, bacteria), formula does not.

2. Bioactive factors in breast milk (changes body’s ‘programming’) → decreased ghrelin secretion → decreased (not excessive) appetite

3. Higher protein content in formula → increased insulin and IGF - 1 (increased risk of being overweight)

Child obesity management

1. Prevention (food availability in schools, nudge approaches, supporting teachers/others in skills building)

2. Treatment/management: Individual assessment (identify unusual eating patterns; assess growth - identify kcal needs vs current intake; behaviours around family eating). Goal is to maintain or not lose weight = support healthy growth. Qualitative food changes for the whole family. Focus on reasonable limits on treats and on increased activity (no longer put children on diets).

   Both are for lifestyle issues.

1. Receiving steroid treatment (oncology). Medications can interfere with child’s ability to tell when they are full. Side effects of steroid: ↑ appetite, weight gain, high BP, ↑ risk of osteoporosis and steroid induced DM

Division of responsibility

Parents responsibility: what, when and where of the meal times

Children’s responsibility: how much and whether or not they eat. It’s okay for them to skip meals. Trust their hunger cues.

Malnutrition definition

Includes both the deficiency and excess (or imbalance) of energy, protein, and other nutrients. Encompasses both undernutrition AND overnutrition.

Causes of malnutrition

Increased nutrient needs (due to acute/chronic illness or injury/trauma), alteration in GI tract function or structure (malabsorption), lack of/limited access to food, cultural or religious practices, limited environmental resources, food insecurity, lack of knowledge, psychological causes

Impact of malnutrition

low birth rates and infant mortality, affects growth and development, depressed immune systems (infectious diseases - mainly undernourished children), disease (due to excessive/unbalanced diet), illness/death, cachexia (metabolic response to inflammation and stress in the body), cycle of malnutrition (populations where undernutrition is a chronic problem)

Why should we care about malnutrition?

Decreased function and quality of life, increased frequency and length of hospital stay, risk of readmission, higher health costs, increased morbidity and mortality

Undernutrition (affects and causes)

undernutrition and low body weight: decline in lean body mass with the potential for functional impairment at multiple levels (i.e. molecular, physiologic, and/or gross motor).

affects: body tissues, functional ability, overall health.

Immediate causes: poor diet, disease

Underlying causes: household food insecurity, inadequate care, limited access to health services

Basic causes (not in individuals control): poverty, war or natural disasters

Diagnosis of undernutrition

Identification of 2 or more of following:

• insufficient energy intake

• weight loss

• loss of muscle mass

• loss of subcutaneous fat

• diminished functional status

• localized or generalized fluid accumulation (outside the blood vessel) that may mask weight loss

  • Protein (albumin) declines → osmolarity declines (is disrupted bc osmosis is out of balance) → fluid leaves the blood vessel and enters interstitial space (space btwn blood vessels)

• increased nutrient needs

• increased energy expenditure

• inadequate protein/energy intake

• inadequate oral intake (of a specific nutrient or in general)

• malnutrition

• underweight

(6) potential outcomes of undernutrition

• specific nutrient deficiencies (iron-anemia, PEM -kwashiorkor/ Marasmus)

• decrease in productivity

• stunted growth (indicator of chronic malnutrition)

• Increased susceptibility to disease (compromised immune system)

• Sarcopenia → abnormal loss of muscle mass in older adults

• Maternal malnutrition (complications during pregnancy, poor fetal development)

Undernutrition & low body weight (causes & consequences)

Can cause a delay in sexual development and increased in malnutrition in elderly.

Low BMI (<18.5)

Significant weight loss (intentional/unintentional) - %UBW or % weight loss in a given amount of time

Failure to thrive (FFT) in infants & children

% UBW

For adult males/non pregnant females

%UBW = (current body weight/UBW) x100

Interpretations:

85-95%: may indicate mild malnutrition

75-84%: moderate malnutrition

<74%: severe malnutrition

% weight change

(UBW - current weight)/ UBW

x100

Failure to Thrive (FFT)

2 definitions:

• weight consistently below the 3rd to 5th percentile for age and sex

• progressive decrease in weight to below the 3rd to 5th percentile for age and sex

On MULTIPLE OCCASIONS in the first 1-2 years of life

For FFT diagnosis, use CDC charts the percentile lines are closer together, more modest.

In WHO charts, the gap btwn percentiles is very large

Protein-energy malnutrition (PEM)

A form of malnutrition in which patients are not meeting their protein and/or energy needs

Marasmus: very low intake of BOTH protein and energy over long period of time. Appear thin, old, dry nails & hair

Kwashiorkor: only protein deficiency (sufficient kcals). Edema in feet, abdomen, and face bc of fluid retention

Dietary management:

Marasmus: energy needs are 4.8-5 kcal per g of tissue to be gained. Potential rate of weight gain varies by age. Greater regain of weight in early life; interventions are more effective.

Kwashiorkor: increased protein intake to 20-50%

Causes of EDs

Genetic: gene dysregulation → affect hunger, satiety, body weight. Inherited personality traits.

Psychological: low self-esteem, need for self-control, unhealthy body image.

Sociocultural: thin body ideals, influences from social media, family, friends, abundant food supply.

ALL interact together.

Symptoms of disordered eating and range of abnormal eating

Symptoms: self-esteem based on body weight, a disturbance on the way their body is viewed, excessive or rigid exercise regime, rigid approach to eating, obsessive kcal counting, anxiety about certain foods/food groups, not eating around other ppl

Wide range of abnormal eating: chronic restrained eating, compulsive eating, habitual dieting, often hunger and satiety are ignored,

Impacts both physical and mental well-being

4 types of clinical EDs from DSM and 4 other types

• Anorexia nervosa: restricting OR binge-purge type (bc of stress about body image)

• Bulimia nervosa: recurrent binge eating with compensatory behaviours (taking laxatives, vomiting or diuretics - called purging)

• Avoidant/restrictive food intake disorder (ARFID): eating or feeding disturbance → failure to meet appropriate nutritional and/or energy needs (bc of sensory issues, fear, etc- NOT due to body image disturbance)

• Binge eating disorder: eating in a discrete period of time. Sense of lack of control over eating during the episode (NO compensatory behaviours)

• night eating syndrome: recurrent episodes of night eating

• Pica: persistent eating of non-edible foods (dirt, feces, ice, glue, hair, etc)

• Prader-Willi syndrome: purely genetic disorder, insatiable appetite (no appetite control hormone, high levels of ghrelin)

• Rumination: repetitive regurgitation of undigested food

Rumination disorder

named after a normal digestive process in ruminant animals

Re-chewed food is swallowed again; but occasionally spit out. Essentially chewing the same food over and over again. Can go on for 30 mins and several times during the day.

2 types: behaviour develops in childhood and persists without severe negative consequences OR associated later with bulimia

Very difficult to diagnose bc done in secret

Consider screening tools for EDs when

Consider screening for ED when the following issues are raised: concern when weight is expressed, girl asking why periods have stopped, sudden changes in growth curve trajectories in teens, teen avoids eating w/ family, mother concerned about daughter hiding food, man asks about getting help for uncontrollable night-time food cravings

Treatment for EDs

reducing prevalence (but “idealistic”), takes btwn 2-7 years to recover, only 50% of ppl fully recover, once ED has developed, ppl usually do not get better by themselves (but they have to want to get better), treatment will depend on severity

Clinical care for EDs

Requires multidisciplinary approach: psychological, medical, nutritional interventions.

ED treatment team: mental health professional, RD, physician

Holistic approach most popular. Biopsychosocial approach often used (medical, behavioural, nutritional and psychological assessments).

Cognitive behavioural therapy (CBT) used

Goals of nutritional rehabilitation

Restore weight.

Normalize eating patterns (sufficient calories for weight gain if AN, challenge forbidden foods, elimination of unhealthy behaviours)

Correct physical and psychological complications of malnutrition

Education: macro/micro nutrient needs, portion sizes, CFG, risks associated with ED

Meal support therapy

Supervision by trained clinical staff (encouragement and emotional support). No current best-practice standards or recommendations.

Intention: reduce fear/anxiety, emotional support, complete meals to meet nutritional needs

Management specific for AN

aim for modest weight gain - less per week as outpatient.

1000-1600 kcal food intake is initial goal.

Studies show using steroids to restore/prevent bone skeletal loss is possible.

Management specific for BN

Goal is eliminating binging and purging.

Not a weight issue; weight goal varies.

TEE or 120-130% above BEE

Macronutrients: same as AN

Refeeding syndrome

Metabolic disturbances bc of reintroduction of nutrition to starved or severely malnourished patients. Life-threatening.

Shift in fluid and electrolytes (3 main ones) from extra- to intra-cellular spaces after feeding. In response to ↑ glucose and insulin levels in blood. Electrolytes then water go in to cells as part of the process of glucose transportation in to cells.

3 main electrolytes:

Hypophosphatemia, hypokalemia (potassium), hypomagnesemia

NICE criteria for determining ppl at high risk of developing refeeding syndrome

Patient has 1 or more of the following:

• BMI less than 16 kg/m²

• Unintentional weight loss greater than 15% within last 3-6 mo

• little or no nutritional intake for more than 10 days

• low levels of potassium, phosphate or magnesium prior to feeding

Patient has 2 or more of the following:

• BMI less than 18.5 kg/m²

• Unintentional weight loss greater than 10% within last 3-6 mo

• little or no nutritional intake for more than 5 days

• A history of alcohol abuse or drugs including insulin, chemotherapy, antacids, or diuretics

Reducing risk of refeeding syndrome

When initiating refeeding: determine caloric and protein requirements using current weight. Start nutrition slowly, providing half of energy requirements.

Carbs: should not exceed 200g/day

Protein: start at goal dose for amounts <1.5g/kg/day

Provide vitamin supplementation

Monitor electrolyte imbalances closely and correct concurrently with nutrition

Monitor heart rate & fluid intake and output

Other issues associated with starting to eat

bloating, constipation or diarrhea, abdominal discomfort, lack of hunger/satiety cues