01

Nutrition Care
for
Obesity
Dian Luthfita Prasetya Muninggar, SGz, MSc

DIETETIC NON-COMMUNICABLE DISEASE

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Definition
• Overweight is a state in which weight exceeds a standard
based on height
• Obesity is a condition of excessive fatness, either
generalized or localized

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Consequences
Associated Chronic Disorders
Metabolic Syndrome
• Glucose Intolerance (FGL > 110 mg/dl)
• Insulin resistance
• Hyperlipidemia (TG > 140 mg/dl)
(HDL < 40 mg/dl {men},
< 35 mg/dl {women})
• Hypertension (BP > 130/mmHg)

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition
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Body Mass Index (BMI)

Body Fat Percentage
Assessment of
Waist circumference
Waist to hip ratio
Obesity
Waist to height ratio
Neck circumference

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Body Mass Index

World Health Organization Collaborating Centre for the Epidemiology of Diabetes Mellitus and Health Promotion for Noncommunicable Disease. (2000). The Asia-Pasific Perspective :
Redefining Obesity and its Treatment.

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Body Mass Index

World Health Organization Collaborating Centre for the Epidemiology of Diabetes Mellitus and Health Promotion for Noncommunicable Disease. (2000). The Asia-Pasific Perspective :
Redefining Obesity and its Treatment.

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Body Fat Percentage

In children (< 15 years)

• BF% = (1.51 x BMI) – (0.70 x Age) – (3.6 x Sex) + 1.4
sex : males = 1, females = 0
Adults
• BF% = (1.20 x BMI) + (0.23 x Age) – (10.8 x Sex) - 5.4
(Deurenberg, P., Weststrate, J. A., & Seidell, J. C. (1991). Body mass index as a measure of body fatness: age- and sex-specific prediction formulas. British Journal of Nutrition, 65(02), 105-114)

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Higher body fat percentage increase health risk, obesity and sindrom metabolic, or even comorbidities

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Higher body fat percentage increase health risk, obesity and sindrom metabolic, or even comorbidities

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Waist circumference
• Subcutaneous fat correlates well to visceral fat

Measuring tape position for waist circumference

Cut-off points
Men > 90 cm
Women > 80 cm World Health Organization Collaborating Centre for the Epidemiology of Diabetes Mellitus and Health Promotion for Noncommunicable Disease.
(2000). The Asia-Pasific Perspective : Redefining Obesity and its Treatment.

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Waist to hip ratio

• Components of metabolic syndrome, disease risk (e.g. CVD, type 2
diabetes and risk factors of CVD) and on hard outcomes such as
mortality.
• Cut-off points
Men 0.90
Women 0.85

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Waist to height ratio

• Considered a better predictor for the detection of • Interpretation of WHtR by Gender
cardiovascular risk factors, than BMI (a) FEMALES MALES INTERPRETATION
• Can be used in different sex and ethnic groups < 0,35 < 0,35 Underweight
and that the same cutoff can be applied in 0,35 – 0,42 0,35 – 0,43 Slim
children and adults(b) 0,42 – 0,49 0,43 – 0,53 Healty
• ‘keep your WC to less than half your height’ 0,49 – 0,54 0,53 – 0,58 Overweight
0,54 – 0,58 0,58 – 0,63 Obese
> 0,58 > 0,63 Very obese

(a) Choi JR, Koh SB, Choi E. Waist-to-height ratio index for predicting incidences of hypertension: the ARIRANG study. BMC Public Health. 2018;18(1):767.
(b) Yoo EG. Waist-to-height ratio as a screening tool for obesity and cardiometabolic risk. Korean J Pediatr. 2016;59(11):425–431.

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Neck circumference
• A useful marker for screening overweight and
obesity in children and adult a
a) HingorjoMR, Qureshi MA, Mehdi A. Neck circumference as a useful marker of obesity: a comparison with body mass index
and waist circumference. J Pak Med Assoc. 2012 Jan;62(1):36-40.

Study Year Population Overweight Male Obese Male Overweight Female Obese Female
Hatipoglua 2010 Turkey Boys (6 – 18 years) : 28 – 38 cm Girls (6 – 18 years) : 27 – 34.5 cm
Hingorjob 2011 Asian-India > 35.5 cm > 37.5 cm > 32 cm > 33.5 cm
Mondalc 2014 Asian-India > 36 cm > 38 cm > 30.9 cm > 33 cm
Lindartoe 2016 Indonesia > 37 cm > 33.5 cm
aHatipoglu N, Mazicioglu MM, Kurtoglu S, Kendirci M. Neck circumference: an additional tool of screening overweight and obesity in childhood. Eur J Pediatr 2010; 169: 733-9.
bHingorjo MR, Qureshi MA, Mehdi A. Neck circumference as a useful marker of obesity: a comparison with body mass index and waist circumference. J Pak Med Assoc. 2012;62(1):36-40.
cMondal N, Timungpi R, Kathar M, Hanse S, Teronpi S, Timung A, Bose K, Sen J. Cut-off point estimation of neck circumference to determine overweight and obesity among Asian Indian adults. Epidemiology,

Biostatistics and Public Health. 2017. 20;14(2).

Lindarto D, Shierly, Syafril S. Circumference in Overweight/Obese Subjects who Visited the Binjai Supermall in Indonesia. Open Access Maced J Med Sci 2016; 4:319-23.

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Waist to height ratio

• Considered a better predictor for the detection of • Interpretation of WHtR by Gender
cardiovascular risk factors, than BMI (a) FEMALES MALES INTERPRETATION
• Can be used in different sex and ethnic groups < 0,35 < 0,35 Underweight
and that the same cutoff can be applied in 0,35 – 0,42 0,35 – 0,43 Slim
children and adults(b) 0,42 – 0,49 0,43 – 0,53 Healty
• ‘keep your WC to less than half your height’ 0,49 – 0,54 0,53 – 0,58 Overweight
0,54 – 0,58 0,58 – 0,63 Obese
> 0,58 > 0,63 Very obese

(a) Choi JR, Koh SB, Choi E. Waist-to-height ratio index for predicting incidences of hypertension: the ARIRANG study. BMC Public Health. 2018;18(1):767.
(b) Yoo EG. Waist-to-height ratio as a screening tool for obesity and cardiometabolic risk. Korean J Pediatr. 2016;59(11):425–431.

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Clinical care pathway for

overweight and obese
adults

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Obesity Management
in Adults

Medical management Nutrition Management

• Lifestyle modification (increased exercise) • Energy Intake Reduction
• Psychological therapy, when necessary • Appropriate nutrient supplementation
• Medications • Nutrition, meal planning, and portion-size
• Surgery education

Who are in charge?

Dietitian, Physician, Sports Medicine Specialists, Psychologist
Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Goals
• Maintain present body weight or achieve moderate loss ® beneficial
• Improvement in body composition
• Management of co-morbidities
• Improving quality of life and well-being
• Achieve ideal body weight

health professionals must help their patients accept more modest, realistic weight loss goals

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Rate and Extent of Weight Loss

• Reduction of body weight involves the loss of both protein and fat, in amounts determined
to some degree by the rate of weight reduction.
• A drastic reduction in calories resulting in a high rate of weight loss can mimic the
starvation response.
• Tissue response to starvation, is one of adaptation to an anticipated period of deprivation
• ADA 2010 recommendations:
– 1st six month : reduction of 10% body weight ® calorie deficits that result in a loss of + 0.25 –
0.5kg/wk (BMI 25-29.9) and 0.5-1 kg/week (BMI > 30)
– the next six months : weight loss ® weight maintenance.

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Treatment Options
• A low calorie macronutrient adjusted eating plan, increased physical activity, lifestyle
modification, and pharmacotherapy
• Surgery plus an individually prescribed eating regimen, physical activity, and lifestyle
modification program
• Prevention of weight regain through energy intake and output balance
• Mindset interventions

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Dietary Modification Recommendation

• Restricted-Energy Diets
• Formula Diets and Meal Replacement Programs
• Extreme Energy Restriction and Fasting
• Very Low–Calorie Diets
• Popular Diets and Practices

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Restricted-Energy Diet
• Most widely prescribed method of weight reduction
• Adequate nutrition, except for energy, which is decreased to the point at which fat stores
must be mobilized to meet daily energy needs
• A caloric deficit of 500 - 1000 kcal daily
• Energy levels : 1200 - 1800 kcal daily
– Carbohydrate 50 – 55 %
– Protein 15 – 25%
– Fat 25 – 30 %
– Vitamin and mineral supplements
• required if there is a daily intake of <1200 kcal for women and < 1800 kcal for men

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Formula Diets & Meal Replacement

Programs
• Goal : to provide structure and replace other higher calorie foods
• Ready-to-use, portion controlled, made with a purchased powder
• Drinks or shakes : milk (casein or whey), pea protein, rice protein, or soy based,
are high in calcium
Per serving : 150 – 250 kkal / 8 oz
Protein 10 – 20 gram
Carbohydrate various amounts
Fat 0 – 10 gram
Fiber 5 gram
Mineral 25 – 30% RDA

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Extreme Energy Restriction and Fasting

• Extreme energy-restricted diets : < 800 kcal/day
• Starvation or fasting diets : < 200 kcal/day
• Rapid weight reduction
– more than 50% are fluid
– leads to serious hypotension
– accumulation of uric acid ® gout, gallstones
– as fat stores diminished ® toxin molecules are released
• affect further weight loss, interfere with the body’s functioning, placing a burden on the liver and even its
ability to continue to lose more fat.
• alter metabolism, disrupt endocrine function, damage the mitochondria, increase inflammation and oxidative
stress, lower thyroid hormones,
• alter circadian rhythms and the autonomic nervous system.
• Extreme energy restriction leads to more disordered eating patterns
Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Current Diet Trends

• Ketogenic diet
• Paleo diet
• Intermittent fasting
• Mayo Diet
• Atkins Diet
• Blood Type Diet
• OCD (Obsessive Corbuzier’s Diet)
• Food Combining Diet

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Ketogenic diet
• Drastically reducing your intake of carbohydrates ® replacing them with fats ®
forcing the body into a state of ketosis
• Not only to reduce intake of unhealthy carbs, but also those that are normally
considered healthy carbs
• Promote disordered eating and an unhealthy relationship with food
• Who should take this diet?
– children with epilepsy ® help to control seizures
– type 2 diabetes ® improve glycemic control

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Paleo diet
• Caveman diet or stone age diet
– eating like prehistoric ancestors will make us leaner and less likely to get diabetes, heart
disease, cancer, and other health-related problems
• High-protein, high-fiber
• Eliminates processed foods, dairy, refined sugar, potatoes, and salt and refined
vegetable oils
• Foods allowed : lean meats, fresh fish, fruits, vegetables, eggs, seeds, nuts, and some
oils such as olive and coconut.
• Inadequate calcium and vitamin D ® should be supplemented.

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Intermittent fasting
• Not what you eat, but when you eat.
– Two non-consecutive "fast" days each week,
– Abstain from eating except for one small meal
• Women : 400 - 500 kcal
• Men : 500 - 600 kcal
– Then for the remaining five "feed" days, you can eat whatever you want
• (+) Suitable for patients who are focused, determined, and motivated in improving
their health goals
– Lose an 5 – 15 kgs + 8weeks.
– Along with regular exercise ® lowering LDL and blood pressure.
• (-) abstaining from food can be difficult & could lead some to disordered eating habits
Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Atkins Diet
• Involves 4 phases
– Starting with very few carbs and eating progressively more until your desired weight
– High protein (25%), high fat (up to 70%)
• By limiting carbs ® body has to turn an alternative fuel ® stored fat is burned
(ketosis state)
• (+) Quick weight loss, fatty food that’s guilt free
• (-) Strict limits on breads and other carbs, raising health concern by eating too much
fat

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Food Combining Diet

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 Recommendation Physical Activity
for Obesity

Donnelly, Blair SN, et al:American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults, Med Sci Sports Exerc 41:459, 2009

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 Recommendation Physical Activity
for Obesity
• Benefit :
– Increases in energy expenditure ® important components of interventions for weight loss and
its maintenance.
– Helps to balance the loss of LBM and reduction of RMR
– Increased strengthening cardiovascular integrity
– Increasing sensitivity to insulin
• USDA recommendation : 60 - 90 minutes PA daily
• Aerobic and resistance training
– Resistance training increases LBM, adding to the RMR and ability to use more of the energy
intake, and increases bone mineral density, especially for women
– Aerobic exercise is important for cardiovascular health through elevated RMR, calorie
expenditure, energy deficit, and loss of fat.
Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Pharmaceutical Management
• For patients with BMI > 30 kg/m2 or BMI > 27 kg/m2 who had significant risk factors
or disease
• Purpose medications:
– decrease appetite
– reduce absorption of fat
– increase energy expenditure
– interfere with energy absorption
• Medication can pose a financial burden to client

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Pharmaceutical Management

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Bariatric Surgery
• Patients with BMI > 40 kg/m2 atau BMI 35 kg/m2 with comorbidities.
• (-) Complications : vitamin deficiencies, electrolyte problems, intestinal failure.

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Liposuction
• 1- to 2-cm incision through which a tube is fanned out into the adipose tissue.
• successful on younger persons with only small amounts of fat to be removed, where
the elastic properties of the skin are able to allow tightening over the aspirated areas.
• not a weight-reduction technique, but rather a cosmetic surgery
– only + 5 pounds of fat are removed at a time.
• Deaths, severe infections, cellulitis, and hemorrhage have occurred with liposuction
surgeries.

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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Poor Methods of Weight Reduction

• Diuretics ® to increase urination
• Stimulants ® to suppress appetite
• Massage ® no evidence to support: waste of time!

Mahan, LK, Escott-Stump, S. & Krause, MV. (2017). Krause's Food & The Nutrition Care Process. 14th Edition

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DIETETIC NCD Raynor HA, Champagne CM. Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults. J Acad Nutr Diet. 2016 Jan;116(1):129-47
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DIETETIC NCD Raynor HA, Champagne CM. Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults. J Acad Nutr Diet. 2016 Jan;116(1):129-47
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Diet Prescription
• BMR (kcal/day) using Harris-Benedict equation:
– Men = 66.5 + (13.7 x ABW) + (5.0 x H) - (6.8 x A)
– Women = 655 + (9.6 x ABW ) + (1.7 x H) - (4.7 x A)
• note : actual weight in kilograms if BMI is < 40; if BMI is > 40 use IBW
• Adjusted Body Weight for Obesity
– AdBW = [ ABW - IBW ] x 0,25 + IBW
• 0,25 ® percentage of excess body weight which metabolically active
– AdBW = [(ABW - IBW) x FFM factors] + IBW
• 0,22 – 0,33 ® Free Fat Mass (FFM) factors for women,
• 0,19 – 0,38 ® Free Fat Mass (FFM) factors for men

Leonberg, L. Beth. ADA Pocket Guide to Pediatric Nutrition Assessment, 2008

Manual of Dietetic Practice, Fourth Edition, Briony Thomas & Jacki Bishop, 2007

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Diet Prescription
• Energy requirement = (BMR x Activity Factors) – Target Energy Restriction
Category Activity Activity Factors
Sedentary little or no exercise, desk job 1,2
Lightly active light exercise/ sports 1-3 days/week 1,375
Moderately active moderate exercise/ sports 6-7 days/week 1,55
Very active hard exercise every day, or exercising 2x/day 1,725
Extra active hard exercise > 2x/day, or training for 1,9
marathon, etc

Leonberg, L. Beth. ADA Pocket Guide to Pediatric Nutrition Assessment, 2008

Manual of Dietetic Practice, Fourth Edition, Briony Thomas & Jacki Bishop, 2007

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Weight Management
• Adoption of healthful and sustainable eating and exercise behaviors indicated for
reduced disease risk and improved feelings of energy and well-being.
• Thinking and emotions :
– perception of weight
– setting realistic goals
– stress management
– balancing acceptance & change
• Weight-management lifestyle :
– balancing diet
– mindful eating habits
– physical activity

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Weight Management
• Weight-management approach :
– self-help books and manuals
– meal replacements
– self-help groups
– professional counselors
– antiobesity prescription drugs
Cautions of safety/ingredients
– over-the-counter drugs and dietary supplements
– surgery

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Assist: Key Take-Aways

1. Emphasize benefits of losing 5-10%

2. Help patients set realistic long-term weight loss goals AND short-term behavioral
SMART goals
3. Reward progress!
4. Prescribe & Refer

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TIP: Ask them to WRITE their goal

down and read back to you

Example #1: I want to lose 10 lbs over the next 3

months
Measurable

Example #2: I will eat 2 servings of vegetables, 5

out of 7 days per week. I will track using notes
section on phone and review weekly by myself
and monthly with PCP.
Next appointment: ___

Example #3: I will walk 4/5 weekdays during

lunch break for 20 minutes. I will track using
physical calendar displayed at my desk. Will
review weekly by myself and monthly with PCP.
Next appointment: ___

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DO / INCREASE AVOID / DECREASE

Stop eating when full Going hungry
Consistent meal schedule Skipping meals
Follow the Healthy Eating Plate model Grazing between meals

Eating late at night

Processed foods like canned meats or
frozen meals
White (sugar, breads, pasta)
Sugary drinks
Alcohol
Trans fats or saturated fats (butter,
red meats, fried foods, chips)

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Peer Group Support/

Psychological Modification
• Group weight loss programs can be helpful
• Emotional eating can disguise an underlying emotional conflict, counselling may
help
• Everyone has a general idea of how much they should exercise/ eat. This does
not change behaviour!
• You have to change the way you think, and that isn’t easy!
• Keeping a journal of your thought processes/talking to others can help

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Common Problems in Obesity

Treatment
• Maintaining Reduced Body Weight
– Energy requirements for weight maintenance after weight reduction appear to be 25%
lower than at the original weight.
– Eating a relatively low-fat (24%) diet
– Eating breakfast almost every day
– Weighing themselves regularly, usually once per day to once per week
– Engaging in high levels (60 to 90 minutes per day) of physical activity
– Support groups are valuable

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Common Problems in Obesity

Treatment
• Plateau Effect
– common experience for the person in a weight reduction program, when weight remains
at the same level for a long period.
– interim plateaus reflect a reduction of lipid in individual adipocytes to some level that
signals metabolic adjustment and weight maintenance
– a release of toxins from adipose tissue that acts as an endocrine disruptor and
inflammatory agent and affects subsequent weight loss. To move out of this phase usually
requires an increase in activity level or a change in food choices to include more fruits and
vegetables which are naturally higher in detoxifying phytochemicals

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Common Problems in Obesity

Treatment
• Weight Cycling
– known as yo-yo effect, repeated bouts of weight loss and regain, occurs in men and
women and is common in overweight and normal weight individuals.
– The effect of weight cycling appears to result in increased body fatness and weight, with
the end of each cycle.
– There are metabolic and psychologic effects that are undesirable.

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What happens to fat cell size & fat

cell number when adults lose weight?
• Fat cells only shrink to a smaller size than adipocytes of nonobese people, and
number of fat cells remains same.
• Fat loss occurs through hypotrophy ONLY
– Which means once you gain fat cells, they never go away, they only get smaller

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Medical Nutriton Therapy

for Obese Children &
Adolescent

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• Childhood obesity increases the risk of obesity in adulthood.

• Obesity tends to run in families. For the child who is obese after 6 years of age,
the probability of obesity in adulthood is significantly greater, if either the
mother or the father is obese.
• If both parents are normal weight – 10% chance of obesity ; If one parent is
obese – 40% chance; If both parents obese – 80% chance
• Obesity that begins in childhood tends to lead to hypertension, elevated LDL
cholesterol, and TGs in adults

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Nurture vs Nature
• Environmental factors influence weight
• Learned eating habits
• Activity factor (or lack of)
• Poverty and obesity
• Overeating learned early in childhood
• Bottle vs breast
• Urging children to eat more, clean their plates
• Use of food as a reward

Is it genetics or learned eating behavior?

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Assessment
• Weight for Height
• Body Mass Index
• Zscore Index

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Weight for Height

Category % Weight for Height
Light obesity 120 - 149
Moderate obesity 150 - 199
Severe obesity > 200
Sumber : Brown DK. Childhood and Adolescent Weight Management. In Dalton S., editor. Overweight and weight management. New York : Aspen : 1997

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Body Mass Index

Percentile range BMI category status
< 5 th percentile Underweight

≥ 5 th dan < 85 th percentile Normal

≥ 85 th dan < 95 th percentile Overweight

≥ 95 th percentile Obese

Nelm, et.al , 2011 Nutrition Therapy and Pathophisiology

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Zscore Index

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Determine the age

0 – 5 years old > 5 -18 years old

WHO 2006’s CDC 2000’s

Weight for Height Graph Weight for Height Graph

Z-score > +1 Weight for Age > 110%

< 2 years old 2 – 5 years old

CDC 2000’s
WHO 2006’s BMI graph
BMI graph Algorithm for application of growth chart on overweight/obese children
taken from Rekomendasi Asuhan Nutrisi Pediatri IDAI (2011)

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Diet Prescription
0 – 3 years - No energy restriction
- Prolonged weight maintenance or slowing of the rate of weight gain, in order to
achieve healthy eating and activity
4 – 6 years - No energy restriction
- Achieve healthy eathing and activity
-Strict monitoring on energy restriction 200 – 300 kcal/day in order to achieve IBW
7 – 19 years - Weight reduction: 1 – 2 kg/month
- Gradually energy intake restriction : 300 – 500 kcal

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Energy Requirement
Age (months) EER (kcal/days)
0–3 (89 x kgs weight) + 75
4–6 (89 x kgs weight) – 44
7 – 12 (89 x kgs weight) – 78
13 - 36 (89 x kgs weight) - 80

Adjusted weight : ideal body weight based on actual height

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Energy Requirement

Age (years) EER (kcal/day)

3 – 8 years Men :
108,5 – 61,9 x Age (years)+ PA x [26,7 x Weight (kg)+ 903 x Height (m)]
Women :
155,3 – 30,8 x Age (years)+ PA x [10,0 x Weight (kg) + 934 x Height (m)]
9 – 18 years Men :
113,5 – 61,9 x Age (years)+ PA x [26,7 x Weight (kg)+ 903 x Height (m)]
Women :
160,3 – 30,8 x Age (years)+ PA x [10,0 x Weight (kg)+ 934 x Height (m)]
Adjusted weight : ideal body weight based on actual height

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Energy Requirement

Source : Leonberg, L. Beth. ADA Pocket Guide to Pediatric Nutrition Assessment, 2008

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Diet Prescription
• 45-60% carbs, 10-35% protein, 25-40% fat
• balanced micronutrient, esp. vitamin D
– Low vitamin D is predominant in obese children ® the systemic inflammatory mediators and
reduced insulin sensitivity pathways
• Dairy : 1 – 2 glass/days (low fat milk)
• Fiber (g/day) = for >3y.o (Age + 5)
• Various menu

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Management Obesity in Children &

Adolescents
• Primary goal ® achieve healthy eating and activity, not to achieve an IBW
• For children < 7 y.o ® prolonged weight maintenance or slowing of the rate of weight
gain, which allows for a gradual decline in BMI as children grow in height.
– If secondary complications are present, and BMI > 95th percentile ®weight loss
• For children > 7 y.o ® weight maintenance (BMI 85th - 95th percentile)
– iIf a secondary complication is present, or if BMI > 95th percentile ®weight loss (+ 0,5kgs/month) is
advised.
• Parent and child readiness to make changes should be evaluated and eating and activity
patterns carefully assessed.
• A slow weight loss of 5 – 6 kgs/year until the optimal adult weight is reached.

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Management Obesity in Children &

Adolescents
• Children or adolescents with BMI > 85th percentile with complications of obesity, or >95th
percentile with or without complications, should be carefully assessed for genetic,
endocrinologic, and psychologic conditions, and secondary complications such as
hypertension, dyslipidemias, type 2 diabetes, sleep apnea, and orthopedic problems.
• If the complications cause serious morbidity and require rapid weight loss, referral to a
pediatric obesity specialist may be necessary.

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Education and Counseling

• Intervention strategies require family involvement and support.

• Families are essential for modeling food choices, healthy eating, and leisure activities for
their children.
• Reducing sedentary behaviors can increase energy expenditure and reduce prompts to eat; the
AAP recommends limiting television and video time < 2 hours/day

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Take-Home Assignment
• Make a graphic info to raise awareness and dietary information about obesity in
children and adult
– Caused & Consequences of obesity
– Healthy activity to prevent obesity
– Balanced diet to prevent obesity
– Tacking diet myth in obesity
• Upload on your social media, and tag me @dianmuninggar
• Deadline : before final exam

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DIETETIC NCD
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DIETETIC NCD
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DIETETIC NCD