PRESENTATION WEIGHT MANAGEMENT CHILDREN

8/7/2019 PRESENTATION WEIGHT MANAGEMENT CHILDREN

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WEIGHT MANAGEMENT FOR OVERWEIGHT AND UNDERWEIGHT CHILDREN

Presented to

the Faculty of the Center for Graduate Studies

Adventist University of the PhilippinesProfessor: Miriam Razon-Estrada, RND, DrPH

In partial Fullfilment of the Requirements for the Course

PHSC 626 WEIGHT MANAGEMENT AND EATING DISORDERS

Submitted by

Thadee Katembo

May 11, 2010


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TABLE OF CONTENTS

Chapter Page

I. THE PROBLEM AND ITS BACKGROUND 3Introduction 3

The Problem 5Significance of the study 5

Scope and Limitations 6

Definition of the Key Terms 6

II. FACTORS AND CONSEQUENCES OF OVERWEIGHT AND

UNDERWEIGHT FOR CHILDREN

8

Factors and complications of overweight and obesity

Factors of Underweight among children

8

10

III.WEIGHT MANAGEMENT FOR CHILDREN

Assessment of Nutritional Status

Management or Intervention

11

11

14

CONCLUSION AND RECOMMENDATIONS 25

REFERENCES 26

Chapter I

THE PROBLEM AND ITS BACKGROUND

Introduction


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goal is to reduce by 50% the prevalence of being underweight among children younger than 5

years between 1990 and 2015. Childhood underweight is internationally recognized as an

important public health problem and its devastating effects on human performance, health, and

survival are well established (de Onis et al, 2004).

Worldwide, underweight prevalence was projected to decline from 26.5% in 1990 to

17.6% in 2015, and the number of underweight children was projected to decline from 163.8

millionin 1990 to 113.4 million in 2015. In developed countries, the prevalence was estimated

to decreasefrom 1.6% to 0.9%. In developing regions, the prevalence was forecastedto decline

from 30.2% to 19.3%. In Africa, the prevalence of

underweight was forecasted to increase from

24.0% to 26.8%. In Asia, the prevalence was estimated to decrease from 35.1% to 18.5% (de

Onis et al, 2004).

According to WHO, Globally, it is estimated that there are nearly 20 million children

who are severely acutely malnourished.2 Most of them live in south Asia and in sub-Saharan

Africa. Current estimates suggest that about 1 million children die every year from severe

acute malnutrition. (WHO, 2007)

According to UNICEF( 2009), worldwide, 14% are still born with a low birth

weight( less than 2500g), 25% of children under five years are underweight, 11% with wasting

and 28% present a stunting status. This situation is particularly alarming in South Asia with the

highest rate of 27% of low birth weight, 45% of underweight, 18% of wasting versus 38% of

stunting. ( The State of the World's Children 2009)

These data reveal that the situation is still far to be improved, whereas we are in the year

2010, ten years from the millennium development objectives were set.


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According to de Onis (2004), about 53% of all deaths in young children are attributable to

underweight, varying from 45% for deaths due to measles to 61% for deaths due to diarrhea.

For the particular case of the Philippines (UNICEF, 2009), low birth weight is 20%. Among

under-five children, 28% are underweight with 6% of wasting versus 30% of stunting.

The Problem

This paper aims to present principles and strategies to be used in weight management for

children.

Specifically, it will answer the following:

1. What are the main factors and consequences of overweight and underweight among

children?

2. What are the efficient strategies of weight management for children in terms of

prevention and treatment?

Significant of the Study

Weight management for children is a very important topic for parents and health

professionals.

1. For parents. To understand factors and consequences is a key to be involved in actions

for the wellness of their children

2. For health professionals. The best prevention of weight management problems starts in

the early childhood.

Scope and Limitations


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The concept of children being wide ( up to 18 years), this presentation has a special

emphasis to children under five years in the following aspects:

Factors and consequences of overweight and underweight.

Strategies of weight management for children in terms of prevention and treatment.

Definition of Key Terms

1. Child. The United Nations Convention on the Rights of the Child defines a child as "a

human being below the age of 18 years. In this paper, the focus is on the under-five years

old.

2. Weight management. It pertains to keep the body weight at a healthy level. It implies

weight loss for obese and overweight, weight maintenance of optimal weight and weight

gain for underweight peoples.

3. Underweight. From age 2 to 20 years , it refers to a BMI that is less than the 5th

percentile.

4. Underweight. For children aged 059 months, using the standard of NCHS/WHO,

moderate underweight is the index weight/age below minus two standard deviations

from median weight for age and severe underweight is the index weight/age below

minus three standard deviations from median weight for age of the NCHS/WHO

reference population.

5. Overweight. From age 2 to 20 years, it refers to a BMI between the 85th and 95th

percentile or weight higher than 120 % of ideal (50th percentile) for height.

6. Obesity . For age 2 to 20, it refers to a BMI equal to or greater than the 95th percentile


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7. Wasting. For children aged 059 months, using the standard of NCHS/WHO, it refers to

the index weight/height below minus two standard deviations from median weight for

height of the NCHS/WHO reference population.

8. Percentile. The set of numbers from 0 to 100 that divide a distribution into 100 parts of

equal area, or divide a set of ranked data into 100 class intervals with each interval

containing 1/100 of the observations. A particular percentile, say the 5th percentile, is a

cut point with 5 percent of the observations below it and the remaining 95% of the

observations above it.

9. Stunting. For children aged 059 months, using the standard of NCHS/WHO, it refers to

the index height/age below minus two standard deviations from median height for age of

the NCHS/WHO reference.

10. Pluricarential syndrome. It refers to a nutritional condition resulting from a reduced

intake or reduced absorption of several nutrients.


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Chapter II

FACTORS AND CONSEQUENCES OF OVERWEIGHT AND UNDERWEIGHT

FOR CHILDREN

The present chapter describe briefly the main contributing factors to the double burden of

malnutrition ( overweight and underweight) among children.

2.1 Factors and complications of Overweight / Obesity among Children

Factors

To understand strategies of intervention, it is a sine qua non condition to identify the

main contributing factors to overweight and obesity among children and teenagers.

Several factors have been listed according to different studies. Below is a summary of them.

1. Having overweight parents, which gave their children a 48 percent chance of becoming

overweight too (Iannelli, 2004).

2. Feedings practices. Parental feeding practices can influence the development of

childrens and adolescents food preferences. Infants have an innate preference for sweet

and salty flavours whereas bitter and sour preferences are acquired. Children consume

what is familiar to them and available to them in the feeding environment.

3. Excessive juice and sweetened beverage consumption. The odds ratio of becoming obese

among children increased 1.6 times for each additional can or glass of sugar-sweetened

drink that they consumed every day. The introduction of juice in the diet of infants

younger than six months is an other aspect of this factor.


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4. Parental restriction of childhood eating. Parents who overly control or restrict their

childs intake in an effort to prevent obesity can produce negative and unintended effects

on childrensfood intake, preferences and satiety. In families with a history of obesity,

research has suggested that parents who have problems regulating their own eating

behavior tend to try to control their childs eating behavior more than families without

obesity and as a result, the child demonstrates a lack of self-regulation.

5. Speed of eating. In several studies from infancy through childhood, overweight infants,

toddlers and children have been shown to eat fast and fail to slow down at the end of a

meal compared to leaner children.

6. Lack of physical activity. In his study on television viewing patterns of boys and girls

ages 8-16 years, Andresen et al found that approximately 50% spent 2-3 hours per day

watching television. Those who watched four and more hours of television daily had the

highest skinfold thickness and BMI than those who watched the least amount of less than

1 hour. (Copperman & Jacobson, 2004).

Complications

There are several complications according to the degree of obesity of the child. The most

frequent are: type 2 diabetes, hypertension, snoring with episodes of apnea or coughing fit and

day time somnolence, orthopaedic complications, hyperlipidemia, gallstones, asthma, insulin

resistance, psychosocial consequences such as school performance, social adjustment, signs of

depression, concerns about weight, eating disorders ( Estrada, 2004).

2.2 . Factors of Underweight among children

Without being exhaustive, the following can be considered among the main factors of

underweight among children.


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1. Low birth-weight (


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3.1 Assessment of Nutritional Status

It has been clear that the first step in the treatment process is to access the childs and

familys nutrition, physical activity, living environment, and psychosocial status.

1. Nutrition Assessment

This step will apply the ABCD of nutrition assessment: anthropometric measurements,

biochemical assessment of blood and urines, clinical general examination, and dietary

assessment. But the focus is here on the anthropometric and dietary assessments.

Anthropometric Measurements

a. BMI System (Children of age 2 to 20 years)

For children, anthropometry will concern the weight and Height to computer the BMI. It

is calculated the same way as for adults. After BMI is calculated for children and teens, the BMI

number is plotted on the CDC BMI-for-age growth charts (for either girls or boys) to obtain a

percentile ranking. The percentile indicates the relative position of the child's BMI number

among children of the same sex and age. The growth charts show the weight status categories

used with children and teens (underweight, healthy weight, overweight, and obese).

(CDC, 2009).

Table 1: Weight Status Categories for the Calculated BMI-for-age Percentile

Weight Status Category Percentile Range of BMI

Underweight Less than the 5th percentile (


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The WHO Global Database on Child Growth and Malnutrition uses a Z-score cut-off

point of


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(school lunch and restaurant dining), prepared foods brought into the house and family food

preparation techniques. (Copperman & Jacobson, 2004).

The same process should be followed, in case of undernutrition to identify the different

factors related to the child and/or to the family for a sustainable intervention.

2. Physical Activity Assessment

An assessment the childs physical activity level should be performed to identify barriers

to increasing both scheduled exercise and habitual physical activity. Careful interviewing

regarding time spend performing sedentary activities such as television viewing, computer use

and electronic game use can reveal excessive periods of inactivity. Discussing the childs

exercise preferences can aid in the formulation of activity goals. (Copperman & Jacobson, 2004).

3. Environmental Assessment

Environment can affect the lifestyle choices made by the patient and family and therefore

must be assessed as part of a comprehensive evaluation. Factors to be assessed are such as family

composition, family income, family schedules, childcare arrangements, food availability, school

environments, community environments with playgrounds, etc. (Copperman & Jacobson, 2004).

4. Psychosocial Assessment or Behavior Modification

An assessment of the childs/ adolescents and parents readiness to make lifestyle

changes is an important measure of whether the weight management program will be successful.

3.2. Management or Intervention

3.2.1. Management of overweight and obesity

Necessity of Prevention since Childhood and Adolescence


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Although it is well-documented that it is possible to reduce obesity modifying energy intake and

expenditure, treatment of manifest obesity in both adults and children has been disappointing , with very

few programs showing lasting weight reduction. (Bergstrom and Hernell, 2005)

Why is it important to fight overweight since the childhood? The origin of adult obesity and its

adverse health consequences often begins in childhood. Adipocytes number increases rapidly during the

first year of life to reach three times the number at birth. Percentage body fat increases from 16% at birth

to about 25% over the first year. By age 6, body fat decreases to 14 % of body mass for girls and 11% for

boys. Thereafter, percentage fat progressively increases to average 16% at age 11 years in boys and 27%

in girls. Children who gain more weight than peers tend to become overweight adults with increased risk

for hypertension, elevated insulin, hypercholesterolemia and heart disease. ( McArdle, Katch and Katch,

2007)

Although it may be easier to treat obesity in children than adults, it is obvious that the best

strategy is primary prevention targeting all children. However as obesity can be regarded as an epidemic

caused by modern lifestyle, effective preventive measures must not focus only on individual behaviour

but also on the social and physical environment for children, supporting more daily physical activities.

(Bergstrom and Hernell, 2005)

Interventions approaches

Once the child or adolescent has been identified as at risk for overweight or overweight,

assessed for lifestyle risk factors and received a medical evaluation, the an intervention with

weight goals can be developed with the child and family.

Table 3 : Recommendations for weight goals for children and adolescents

Ageyears

BMI85th-94th %ile)

BMI95th %ile

Absence of medicalcomplications

Presence of medicalcomplication

2-7 X Weight maintenance Weight maintenance

2-7 X Weight maintenance Weight loss

>7 X Weight maintenance Weight loss*

>7 X Weight loss* Weight loss*


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*Children and adolescents in this group should be encouraged to reduce their weight by 1 pound (0.45kg)

per month to eventually achieve a BMI less than the 85th percentile.

Medical complications include mild hypertension, dyslipidemias, insulin resistance, sleep apnea, genu

varum, and cutaneous candidiasis.

Treating pediatric overweight with a family-centered multidisciplinary approach

addressing nutritional, physical activity, and psychosocial issues offers the best chance at

achieving lifestyle changes and weight goals.

1- Parental Support and Behavioral Modification

Parental involvement is an integral component of pediatric weight management. When

the child/teenager and his or her parents or caretakers are ready to make lifestyle modifications,

the family can learn to support the child utilizing two different strategies: the cognitive

behavioral and the motivational interviewing.

a- Cognitive behavioral strategies

This is a theory of learning for behavioral change that describle learning as a

reciprocal relationship between behavioral, environmental and personal factors.

The key components of this approach include nutrition education on lifestyle

behaviours and their relation to chronic diseases, modification of the home/school choices, self

monitoring, family commitment to long-term and frequent follow-up.

b- Motivational interviewing

Traditionally used in substance abuse counselling, this approach is being considered

now as a potentially effective adjunct to weight management interventions. It addressesn the

ambivalence of wanting to modify lifestyle behaviours that many patients and their families

express to practitioners. Through this patient-centered approach, the patients identify

discrepancies between their current behaviour and desired goals, acknowledging ambivalence

rather than ignoring it. Utilizing an emphatic interactive listening style to increase the patients


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and families motivations, the practitioner actively elicits the patients articulation of behavior

change.

2- Diet therapy intervention

Here are several different dietary approaches to help change childrens, adolescents and

families eating patterns.

A. General Principles for Age appropriate interventions

Children and adolescents at risk for obesity, whose goal is weight maintenance, should

be followed monthly by a registered dietitian and/or a paediatrician. Thosewho have a BMI

95

th

percentile should be monitored at least every 2 weeks during the weight loss phase and

monthly during weight maintenance.

Infants :

- Promote breastfeeding

- Counsel to avoid juice prior to 6 months of age

- Encourage water as a between feeding beverage

- Adequate transition from exclusive breastfeeding to family foods, referred to as

complementary feeding, from 6 to 18-24 months of age ( whole grains flour )

- Increase water, fruits and vegetables progressively

- Decrease sweetened beverage, juice, refined carbohydrate and saturated fat

consumption

- Advice slow down when eating

- Controlling feeding practices by the mother

School-age child and adolescent:

- Healthy snack suggestions


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- slow down when eating ( wait 30 min before 2nd portions)

- Increase water intake

- Decrease TV viewing

- Family activity suggestions

B. Nutritional Guidelines

The Food Guide pyramid

- Increasing fruit, vegetable and whole grain consumption ( brown rice, wheat bread) while

decreasing sweetened beverage, juice, refined carbohydrate and saturated fat

consumption will improve the nutritional quality of the diet and reduce excessive caloric

intake.

- The American Academy of Pediatrics recommends adolescents limit their juice intake to

two 6 fl oz servings per day or half the recommended fruit servings each day

Traffic Light or stoplight Diet

For preschool and preadolescent children, Epstein et al (1990) have been used the

stoplight diet which is a plan of 900-1300 kcal per day.

Low gylcemic index, low fat diet

Theglycemic index of a food (GI) is the glycemic response after the consumption of a

specific food . In other words, it is a measure of the effects of carbohydrates on blood sugar

levels. To be more explicit, the glycemic index (GI) rates carbohydrate foods on how quickly

blood sugar / glucose levels increase in the 2 - 3 hours after eating as the carbs are converted into

glucose. (http://optimalhealth.cia.com.au/gi17.html)


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At Schneider Childrens Hospital Center for Atherosclerosis Prevention, the meal plan

limits refined carbohydrate consumption with specific macronutrient goals of 50% carbohydrate,

20% protein and 30% fat. It encourage the consumption of lean meats, fish and poultry, low-fat

dairy products, monounstaturated oils, whole grains and fresh fruits and vegetables (Copperman

& Jacobson, 2004).

Table 4: Glycemic Index of foods

Low Glycemic Index Foods

(Score under 50)

Moderate Glycemic Index foods

(Score 50-70)

High Glycemic Index foods

(Score >70)

Barley

GrapefruitKidney beans, lentils

Apple, pear, peach

Orange, grape

Non fat plain yogurtLow fat milk

Sweet potato

Whole wheat breadCorn, popcorn

Brown rice, couscous

Whole wheat pita

Green pea soupApricot, mango

Whole grain pasta

White bread

Rice cakesFrench fries

Cornflackes

Baked white potato

Instant white riceCandy, regular soda

(Copperman & Jacobson, 2004).

Protein sparing Modified Fast (PSMF)

- The diet consists of caloric restriction between 600-900 caloriesper day, 1.5 to 2.5 grams

of high biological value protein per kilogram of weight per day and extremely limited

carbohydrate and fat intakes.

- A minimum daily consumption of 1.5 liters of water is recommended. It requires

supplementation of vitamins and minerals to maintain nutrient adequacy ad close

monitoring of serum electrolytes.

- This diet requires medical supervision by multidisciplinary team.

Very Low carbohydrate, High-fat Ketogenic Diet


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The use of Very Low carbohydrate, High-fat Ketogenic Diet that induces ketosis

(overproduction of ketones) to promote weight loss has a distinct advantages in shor-term

treatment of overweight adolescents.

The ketogenic diet is a special high-fat, low-carbohydrate diet. The name ketogenic means that it

produces ketones in the body (keto = ketone, genic = producing). Ketones are formed when the body uses

fat for its source of energy. Usually the body usually uses carbohydrates (such as sugar, bread, pasta) for

its fuel, but because the ketogenic diet is very low in carbohydrates, fats become the primary fuel instead

The same diet helps also to control seizures in some people with epilepsy.(Schachter, 2008)

From a 12-week randomized, controlled adolescent weight reduction study of

40subjects(Sondike et al, 2003), the ketogenic consisted of 20 grams of carbohydrate and ad-lib

intake of protein,fat and energy for the intial 2 weeks. For weeks 3-12, carbohydrate intake was

increased to 40 grams daily by promoting nut, fruit and whole grain consumption and

consumption of fluid intake of 60 oz per day ( 1 ounce =29.57 ml). Electrolyte imbalance and

micronutrient deficiencies were averted bu addition to meals of an iodized salt containing a

misture of sodium cholird, potassium cholird,a nd a multivitamin supplement daily. (Copperman

& Jacobson, 2004).

3- Physical activity

Incorporating physical activities (such as using the steps instead of an elevator or walking

more and driving less) into daily routines can improve weight management outecomes.

- Decreasing sedentary activity by limiting television viewing has shown improvement in

BMI in children. The American Academy of Pediatrics recommends limiting television

viewing to 1-2 hours per day.

- Parents need to promote and model increased physical activity and decrease sedentary

activities for the family. Strongly encouraging children to play outside after school for 30


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the United Nations System Standing Committee on Nutrition and the United Nations Childrens

Fund have come up with a joint statement on a new strategy named Community-based

management of severe acute malnutrition. Uncomplicated forms of severe acute

malnutrition should be treated in the community (WHO, 2007).

Here is the Guideline as followed in the Democratic Republic of Congo.

Phase 1 - Recovering normal metabolic function and rehydration.

Patients without an adequate appetite and/or a major medical complication are initially admitted

to a hospital for Phase 1 treatment.

- During this phase patients are given a therapeutic milk formula called F-75(meaning 75

kcal/100ml of solution ) and energy intake is 100 kcal/Kg/day.

- ReSoMal(oral rehydration salts solution for severely

malnourished children).

Table 5. Recipe for ReSoMal oral rehydration solution

Ingredient Amount

Water (boiled & cooled) 2 litresWHO-ORS * 1 litre-packet

Sugar 50 g

Electrolyte/mineral solution 40 ml

- Medical treatment of complications

Transition Phase ( if necessary).

During this phase the patients start to gain weight slowly as a fortified milk formula

called F-100 or a Ready-to-Use Therapeutic Food (RUTF) is introduced.

Phase 2 - Gaining weight with the right kind of therapeutic food. (Community level)

This phase receives patients from the phase 1 and when there is no any complication, the

treatment start by this phase, the Community-based management of severe acute malnutrition.


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The central principle of this approach is to detect severe acute malnutrition before the

life-threatening symptoms and treat malnourished children in their homes, rather than having

them travel for miles for help.

The principle of treatment is the use of the Ready-to-Use Therapeutic Food (RUTF). No

use of milk like the formula F-100 because it needs to be prepared by trained personnel and

presents a risk of contamination due to its high water content.

We have three main RUTF used:

Plumpy Nut

Ingredients : Plumpy Nut is composed of peanut butter, vegetable fat, dry skimmed milk,

lactoserum, maltodextrines, sugar, mineral and vitamin complex.

Table 6. Nutritional value of Plumpy Nut

Energy 545 Kcal/100gr. One sachet (92gr) is 500 Kcal; 10% of protidics calories /

59% of lipidics calories.

Vitamins: vit A (910mcg), vit D (16mcg), vit E (20mg), vit C (53mg), vit B1

(0.6mg), vit B2 (1.8mg), vit B6 (0.6mg), vit B12 (1.8mcg), vit K

(21mcg), biotine (65mcg), folic acid (210mcg),pantothenic acid

(3.1mg),niacin (5.3mg).

Minerals Calcium (320mg), Phosphorus (394mg), Potassium (1111mg), Magnesium(92mg), Zinc (14mg), Copper (1.78mg), Iron (11.53mg), Iodine (110mcg),

Sodium (189mg), Selenium (30mcg).

- How to use it ?

Child of height >85cm: 5 sachets /day ( that is 2500 Kcal)

Child of height


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Minerals, Milk calcium, Amino acids, Vitamins.

Table 7. Contains only vegetable ingredients with the exception of the milk constituents.

Weight % Energy %

Protein 14,5 % 11 %

Fat 31,0 % 53 %Carbohydrate 47,5 % 36

- How to use it?

BP100 (529.4 Kcal/100gr) and One bar of BP-100 (56.7gr) is 300 Kcal.

Child of height >85cm: 9 bars /day ( 2700 Kcal)

Child of height 40 8(4000Kcal) 56

(Compact for life, http://www.compactforlife.com)


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CONCLUSION AND RECOMMENDATIONS

To present the main factors and consequences of overweight and underweight among

children and the efficient strategies of weight management for children in terms of prevention

and treatment, these were the objectives of this presentation.


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Considering the double burden linked of overweight and underweight among children,

their weight management needs a particular attention for both parents and health professional as

consequences are numerous in their future life.

Factors of overweight are more related to the diet intake, the lack of exercise, all coupled

to a need of behaviour modification. The key of success is prevention for both two aspect of

weight problems. However, when overweight and obesity is already presented, the three major

actions are the behaviour modification by health and nutrition education, the diet therapy and the

physical therapy.

Regarding the developing countries, it is not yet the time to ignore the problem

underweight due to malnutrition among children with the underlying factor of malnutrition

during the pregnancy and the high prevalence of low birth weight. Interventions should consider

those factors for prevention while taking care of those who are already sick. The current strategy

to involve also parents in the community-base management of acute malnutrition would help to

lead them for more responsibility. Above all, there is a need of political engagement in the

resolution of malnutrition in developing countries.

REFERENCES

Alasfoor,D, Traissac,P., Gartner, A. & Delpeuch,F .(2007) Determinants of persistentunderweight among children, aged 6-35 months, after huge economic development and

improvements in health services in Oman. Journal of Health Population and Nutrition,

Sept, 2007. http://findarticles.com/p/articles/mi_6829/is_3_25/ai_n28474652/


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Schachter, S.C.(2008).Ketogenic Diet. Retrieved on May 9, 2010 fromhttp://www.epilepsy.com/epilepsy/treatment_ketogenic_diet.

UN (1989).Convention on the Rights of the Child The Policy Press, Office of the UnitedNations High Commissioner for Human Rights) Retrieved on May 2, 2010 from

http://www.hakani.org/en/convention/Convention_Rights_Child.pdf

UNICEF. The State of the World's Children 2009

WHO, WFP, UNICEF & UNSSCN (2007). Community-based management

of severe acute malnutrition.Retrieved on May 2, 201o from

http://www.who.int/nutrition/topics/Statement_community_based_man_sev_acute_mal_eng.pdf

WHO (2006), Overweight and Obesity, Fact sheet N0 311. Media centre:

http://www.who.int/mediacentre/factsheets/fs311/en/index.html, Accessed July 15, 2009

In the context of malnutrition by nutrient deficiency.

Voir PCCMA of OMS


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Conclusion


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population.


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The State of the World's Children 2009, Maternal and newborn health crisis

http://www.unicef.org/sowc09/statistics/tables.php
http://www.unicef.org/sowc09/statistics/tables.phphttp://www.unicef.org/sowc09/statistics/tables.php


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http://www.sarpn.org.za/documents/d0001945/Nutrition-strategy_WorldBank_5.pdf


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Traitement de la malnutrition aigu svre

http://www.compactforlife.fr/traitement-de-la-malnutrition/
http://www.compactforlife.fr/traitement-de-la-malnutrition/http://www.compactforlife.fr/traitement-de-la-malnutrition/http://www.compactforlife.fr/traitement-de-la-malnutrition/http://www.compactforlife.fr/traitement-de-la-malnutrition/


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PRESENTATION WEIGHT MANAGEMENT CHILDREN