Dietetic paediatric weight management

service

Gemma Moore, Paediatric Dietitian

Referral to the primary care dietetic paediatric weight management service - criteria

• Children or young people aged between 0 and 16 years.• Children or young people who have a body mass index on the 91st – 98th centile.• Children or young people who have a body mass index >98th centile who have stable obesity

related co-morbidities that have been investigated and treated by a paediatrician.• Before a referral can be made to the Dietetic service, the following needs to be completed and

included with the referral form:– An assessment of weight, height and BMI.– Services available in Somerset to support healthy lifestyles to be explained to the child and

their family.– Signpost to available resources that will help the family to make changes towards a healthier

lifestyle. – Goals have been set and reviewed at least once before referral. – Implemented advice and progress with goals should be documented clearly on the referral

form. – Complete the ‘Ready to change form’ and include this in the referral documentation*.

• Referrals will be returned to the referrer if any of these factors have not been completed and included with the referral form.

*Rationale - children, young people and their families who are motivated and ready to make changes are able to engage well with the dietetic service. These families benefit most from the service and are most successful at making and maintaining long term lifestyle changes.

• Children or young people who have a body mass index >98th centile who have serious untreated obesity related co-morbidities that have not been previously investigated by a paediatrician.

• Children, young people or families who are unable or unwilling to make lifestyle changes due to unresolved medical, behavioural or psychological issues.

• Eating disorders, including binge eating disorders.• Children with very complex needs (e.g. severe learning or educational

difficulties).• Children or young people who have failed to lose and/or maintain weight after

6 months in the primary care dietetic weight management service. • Children, young people or families who do not engage with the service. The

child or young person will be discharged from the service if they do not contact the dietetic department to book an appointment within 2 weeks of receiving an invitation letter to book an appointment. The child or young person will be discharged if they fail to attend one appointment or if they cancel more than 2 appointments consecutively.

Exclusion criteria

Resources [1]Growth chartsGrowth charts and BMI charts can be downloaded and printed

from the RCPCH website.• Growth chartshttp://www.rcpch.ac.uk/growthcharts• BMI charthttp://www.rcpch.ac.uk/system/files/protected/page/GIRLS%20and%20BOYS%20BMI%20CHART.pdf

Resources [2]Healthy eating – toddlersThe infant and toddler forum website provides downloadable leaflets

free of charge for a range of health issues in toddlers. Leaflets cover a range of topics including healthy eating, portion sizes and fussy eating.

• Healthy eating for toddlershttps://www.infantandtoddlerforum.org/c/document_library/get_file?uuid=224ed0de-9017-4a81-8154-47eba1593671&groupId=11803

• Meals, snacks and drinks for toddlershttps://www.infantandtoddlerforum.org/c/document_library/get_file?uuid=ac042eba-f8fe-4cc8-9ee1-4be510506921&groupId=11528

• Portion sizes for Children 1-4 yearshttps://www.infantandtoddlerforum.org/c/document_library/get_file?uuid=ac042eba-f8fe-4cc8-9ee1-4be510506921&groupId=11528

Resources [3]Healthy eating - teenagers• Getting the balance right 11-16 yearshttp://www.teenweightwise.com/upload/kids/pdf/leaflets_english_gettingbalance_11_16_bdang019.pdf• Getting the balance right 16+ yearshttp://www.teenweightwise.com/upload/kids/pdf/leaflets_english_gettingbalance_16plus_bdang020.pdf• Eating outhttp://www.teenweightwise.com/upload/kids/pdf/factsheets_english_eatingout_bdang005.pdf

• Packed luncheshttp://www.teenweightwise.com/upload/kids/pdf/factsheets_english_packedlunches_bdang006.pdf

• Quick, cheap and easy foodhttp://www.teenweightwise.com/upload/kids/pdf/factsheets_english_quickcheap_bdang007.pdf

• Quick recipe ideashttp://www.teenweightwise.com/upload/kids/pdf/factsheets_english_quickrecipes_bdang008.pdf

Resources [4]Portion sizes• Eating Well First Year Of Life http://www.cwt.org.uk/pdfs/CHEW-1stYearLifePracticalGuide.pdf • Eating Well For 1-4 Year Olds http://www.cwt.org.uk/pdfs/CHEW-1-4YearsPracticalGuide-2ndEd.pdf • Eating Well For 5-11 Year Olds http://www.cwt.org.uk/pdfs/CHEW-5-11Years-PracticalGuide.pdf• Eating Well For 12-18 Year Olds http://www.cwt.org.uk/pdfs/CHEW-12-18Years-PracticalGuide.pdf

Snacks• https://smartswaps.change4life.co.uk/• http://www.nhs.uk/Change4Life/Pages/healthy-snacks.aspx • http://www.nhs.uk/Livewell/loseweight/Pages/surprising-100-calorie-

snacks.aspx

Resources - Dietetic

Case Study• Referral from consultant paediatrician for weight management

advice in September 2012. Had seen 2 different Dietitians at 2 different appointments since then.

• Referred to my care in June 2013 (new post holder), aged 11 years and 6 months.

• Female. • Medical history: Epilepsy, hemi-plegia and cerebral palsy. Mum

feels this condition limits her ability to increase exercise and mum feels that the medication makes it difficult to lose weight.

• Medication: Lamotrigine, Levetiracetam – giddiness and nausea associated with medication.

• Social: Lives with mum and dad.

Initial appointment June 2013

• 11 years and 6 months old. • Weight: 102.9kg, Height: 1.63m, Body Mass Index (BMI): 38.6

kg/m2.Young lady has stopped going to slimming world and has

subsequently gained 4kg in weight over 4 months. • Mum’s concerns: low motivation and frustration at having to think

about healthy eating constantly. She also feels that the young lady has a large appetite.

• Consultation: discussed methods to control hunger and cravings (drink more water, fill up on salad and vegetables, wait for 20 minutes if having a craving, distract self from craving). Also discussed motivation and completed an ‘ambivalence grid’.

• Aim – to reduce BMINegotiated goals:

1) If hungry - have a small piece of fruit or drink water.2) Mum to speak to staff at school about reminding young lady to drink water.3) Start walking to school from tomorrow.3) Activity ideas for summer holidays provided.4) Re-start slimming world. R/V 2/12.

BMI chart

Review September 2013• Weight = 107.1kg (above 99.6th centile) - increase of 4kg since 1st

appointment in June. Progress with goals: struggled to make changes over the summer holidays.

Has now started school and routine is helping with healthier lifestyle. Negotiated goals: • To join slimming world or to be weighed every fortnight by school nurse.• To go for a walk 2 days per week after school on days that she does not

have P.E.• Find clubs to join at school• Mum to speak to school about lunchtime staff helping her to choose

healthy options at lunch. Dietitian will ask school for their menu to discuss at next appointment.

• Fish and chips once a week at school lunch as a treat• Fist sized portion starchy carbohydrates at meals.

R/V 1-2/12.

Review December 2013

• Weight 108.9 kg (above 99.6th centile) – increase of 1.8kg since her last appointment.

Progress with goals: ? Level of motivation. Likely motivation is low.• Young lady joined Slimming World but often refuses to attend. • Mum reported that young lady struggles to get motivated to go for walks. • Young lady has not joined any clubs at school. • Dietitian contacted School by email but they were in the process of changing

catering providers and could not provide information about the school menus. • Young lady has stopped having cakes at school, but mum is concerned about

the menus at school and mum does not feel that they provide healthy options.• Mum told me that young lady has a small meal in the evening.Negotiated goals:

• To stop school lunches and to change to packed lunches.• To go for a walk on at least 2 days per week.• To complete a food diary or photograph diary of dietary intake every day.• To be weighed weekly by mum (found this helpful at Slimming World).• To speak to nan about the healthy eating plan.

R/V 1/12.

Reported dietary intake:

Breakfast - 35g weighed shreddies or rice krispies or 2 x weetabix/shredded wheat with canderel and skimmed milk.

Lunch - school meals. Lasagne/large baguette. No cakes.

Evening meal - small portions. Fruit for dessert.

Review January 2013• Weight: 104.2 kg (above 99.6th centile). Young lady has done

brilliantly to lose 4.7kg• Height: 165.5cm (98th centile).• BMI: 37.7kg/m2 (above 99.6th centile + 3.5 SDS). Progress with goals: Young lady is motivated and has done really

well to meet nearly all of her goals since her last appointment. • To go for a walk on at least 2 days per week. She has worked

towards this goal and she has been going for a walk once a week. • Mum had been writing a food diary and counting calories for

young lady. Aims for 1300-1800 calories per day.• Young lady has monitored her weight regularly. • The healthy eating plan has been discussed with her nan and dad

and they have been supportive by not buying her sweets and chocolate and not offering second helpings.

Negotiated goals:• To continue with packed lunches at school.• To go for a walk on at least 2 days per week.• To complete a food diary for an agreed amount of time each month e.g. 3 days per month to refocus on portion sizes. • To be weighed weekly by mum.

R R/V 3/12.

Review March 2014• Weight: 100 kg (above 99.6th centile). She has done brilliantly to lose 4.2kg .

Lost a total of 8.9kg (1 stone and 6 pounds) since December. • Height: 167cm (98th centile)• BMI 35.8kg/m2 (above 99.6th centile + 3.5 SDS)

Progress with goals: Motivated. Met all of her goals since her last appointment.• She now has her trike and goes out on this at least once weekly. • Has been weighed frequently at home, which has been really useful. For

example, when she put on 1kg in weight, she was able to be stricter with her diet and lost the 1kg in weight again. This is a great achievement and has meant that she has been able to maintain her weight loss.

Negotiated goals: • To continue with packed lunches at school.• To go for a walk/cycle at least once per week.• To complete a food diary for an agreed amount of time each month e.g. 3 days per month to refocus on portion sizes. • To be weighed weekly by mum.

R/V 3/12.

Progress with reducing BMI

Long term plans• To support family with continual weight loss as

much as required (agree with family that support will be provided as long as young lady continues to lose weight).

• To discuss lapses and relapse prevention.• To review less frequently to re-evaluate goals (i.e.

every 6 months).

Questions?