Transcript Childhood Obesity: More Than Just BMI

Childhood Obesity: More Than Just BMI
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.
• According to the NHANES survey from 19761980 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 3rd 2009, 2009.
Illinois 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 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 3rd
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 3rd 2009, 2009.
Childhood 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
Pathophysiology 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.
• In 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.
Ghrelin 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.
• However, 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.
Contributing 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.
American 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 5th 2009
C.W.
Patient 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 3rd grade.
• He has two older
female siblings and two
parents that have been
divorced for four years
now.
Living 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.
Patient Profile: CW
• Past Medical History:
– Attention Deficient Disorder (ADD)
• Diagnosed two years ago.
• Current Symptoms:
–
–
–
–
–
Excessive thirst
Excessive hunger
Inability to pay attention
Tiredness
Sleep 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.
Diabetes 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.
Risk 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.
Weight History
• CW has been overweight since birth tipping
the charts at the 90th to 95th 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.
Parent 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.
Parents 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.
Nutritional Data
• Height: 5’0 feet
– Above the 97th percentile for stature-for-age
• Weight: 158 pounds
– Above the 97th percentile for weight-for-age
– Taken at doctors office at the end of February
• BMI: 30.8
– Above the 97th percentile for BMI-for-age
• UBW: Varies since he is a child.
– Gaining 1-2 pounds/month
Medications
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, 14th ed. Birchrunville, PA: FoodMedications 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
Normal
Total Cholesterol
< 120-199 mg/dL
2/20/09
156 mg/dL
Normal
LDL
< 100
2/20/09
80 mg/dL
Normal
HDL
> 40
2/20/09
43 mg/dL
Normal
Typical Day for C.W.
Breakfast
Lunch
Dinner
Snack
•2 cups of cereal, which is
either Cookie Crisp or a
peanut butter chocolate
cereal with one cup of 2%
milk
• 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.
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
After School Snack:
•Animal crackers
•Graham crackers
•Yogurt with soda.
•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
- Mother will sometimes
pack him fruit and cheese
to eat with his lunch but
she is not sure if he eats
it.
Evening Snack: When
father picks children up
around 7 pm every night,
he likes to “treat” them
with an ice cream
sundae.
Nutrient 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 servings
– 9 from simple carbohydrates
• Protein: 11%.
– 5.0 servings of lean protein sources
• Fat: 38%
– 23 servings
• Fruit: 3.5 servings
• Vegetables: 3 servings
• Milk: 1 servings
Personnel 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
Personnel 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.
Personnel 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.
Personnel 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.
Current 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.
Diet 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 day
Physical activity: 60 minutes per day
1800 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
Diet 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 4th 2009
Dietary Interventions
Dietary Interventions include the use of:
1) Balanced macronutrient diets
1)By age Groups
2)Selected Diets
2) Altered macronutrient diets
Balanced 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 4th 2009.
Selected Diet Approaches
1) Stop Light Diet
2) Food Guide Pyramid
• 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.
• 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 4th 2009
Altered Macronutrient Diets
• Low Fat
• Altered 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 4th 2009
Physical 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
5th 2009
Treatment 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 5th 2009.
Treatment Focus
Prescribed Diet and Nutrition Education
• It has been shown that including a
prescribed diet plan as part of a multicomponent weight-management program
results in improvements in adiposity in
children in both the short-term and longerterm (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 5th 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
Other 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.
Sample 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 meat
1 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 vegetables
1 small salad with lettuce tomatoes,
onions, and cucumbers
2 tbsp of low fat salad dressing
1 tsp margarine
Snack
1 cup of skim milk
3 graham cracker squares
½ cup of unsweetened applesauce
Short Term Goals for C.W. and Parents
• Aim for a healthy well rounded
diet
• Increase physical activity to one
hour per day
• Increase fruits and vegetables to
three to five per day
• Decrease TV viewing time to one
hour per day
• Increase low fat milk
consumption
• Have divorced parent’s work
together in planning meals and
grocery list in order to have the
same foods at both homes.
• Decrease fast food consumption
by limiting to once per week
• Decrease soda and sugary
beverage consumption to once a
week
•
Work on portion control
• Work on having the parents pack
the child’s lunch to school every
day
Long Term Goals for C.W. and Parents
•
•
•
•
Weight Maintenance
Improved 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.
ADIME 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 97th 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.
ADIME: 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.
ADIME: 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.
Certificate Opportunity
• June 15-17, 2009
• Certificate 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
THANK YOU!
Sincerely,
Erica Timmermann
References
[1] Centers for Disease Control and Prevention. Overweight prevalence. Available at website:
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/prevalence.htm. Assessed April 3rd 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 3rd 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 3rd 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.
References
[8] Wikipedia: the free encyclopedia: Ghrelin. Available at website: http://en.wikipedia.org/wiki/Ghrelin.
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