Project:Sandbox

Abstract
In management of childhood and adolescent obesity, diet modification forms the cornerstone of management. Diet modification has to follow scientific evidence based principles keeping in mind the age, the family and social structure, parental education , likes and dislikes of the child and specific medical needs.

The main principle is to achieve gradual sustainable reduction in body weight till the ideal weight is achieved and to maintain a healthy and optimal body weight for height and frame and prevent complications of obesity

INTRODUCTION
People who are chronically overweight have shorter life expectancies, and suffer more health problems and complications than slender people, which include diabetes, heart disease, high cholesterol, high blood pressure, and many others.

That makes weight management a top priority. Maintaining a healthy, optimum body weight for the height and frame is probably the single most important thing one can do for  health. The main principles are- slow and gradual reduction of body weight till it is closer to ideal body weight, maintenance of weight loss achieved and prevention of complications.(1)

When it comes to weight loss, starvation diets offer no satisfactory, permanent solution. Severe caloric restriction causes the metabolism to slow down and go into low gear as a survival mechanism, Research has shown that the calorie density of our diets will impact our weight (2). The calorie density is the amount of calories in a given weight of food. Consuming foods that are considered low-calorie dense aids in weight loss. These foods will provide a high volume without a lot of calories. The American Heart Association recommends a diet with 25% to 35% of calories from fat. Besides providing taste to diet, dietary fat has other functions. There has been a considerable amount of research showing the health benefits of omega-3 fats, including protecting heart. Dietary fat is also needed to transport the fat-soluble vitamins A, D, E, and K. Without fat to transport them, they will not be able to serve their functions in your body (3). Our diets are meant to have a balance of protein, carbohydrates, and fat. The Dietary Reference Intake (DRI) established the need for each one of these nutrients based on research for optimal health and weight. The DRI set the dietary goals at 45% to 65% from carbohydrates, 20% to 35% from fat, and 10% to 35% from protein (4)

DIETARY MODIFICATIONS
Following points are to be taken into consideration for dietary management of obesity:

i) Restrict total food intake : For  restriction of total food intake, make a note of foods one (obese individual) eats daily as parts of meals and also snacks. Calculate the total energy intake .Compare total intake with RDls. Find out the extent of energy restriction required for weight reduction .Start reducing 200-300 Kcal per day and slowly more can be achieved.  . First cut down on the extra tit bits one tends to eat in between. Give smaller meals at regular intervals. Don't miss a meal or  one will tend to eat a lot more in the next meal. Do not eat while watching television or reading.

ii) Cut down intake of fat and fat-rich food : .. Give visible fats in the form of cooking oils. Avoid giving ghee, butter of-hydrogenated fats-they have more of saturated fats and cholesterol Avoid giving fat-rich foods like meats, cakes, pastries, fried snacks, nuts and oilseeds. iii) Give more of protein rich food :  Milk (toned low fat ), pulses, lean meats, chicken, fish. iv) Give more of leafy vegetables and yellow and orange fruits : They provide the basic protective and regulatory nutrients.

v) Give more fibre rich foods : Whole cereals, whole pulses, fibrous fruits and vegetables. Fibrous foods have more satiety value and hence tend to satisfy hunger and at the same time provide less energy (calories). (6)

Besides dietary modifications; physical exercise and psychological support are also important components of treatment of obesity.

It is necessary to find out meal schedules, work patterns, likes and dislikes of food. Tight food schedule is to be avoided as it is difficult to adhere .Suggest only few dietary modifications in earlier meal pattern. Regulation of the meals consumed is essential. Diabetic individuals should be encouraged to have meals at regular intervals. It is advisable not to skip meals or keep a fast. Main meals consumed should provide fairly even amount of calories.

A number of factors influence glycemic responses to foods (7), including the amount of carbohydrate, type of sugar (glucose, fructose, sucrose, lactose), nature of the starch (amylose, amylopectin, resistant starch), cooking and food processing (degree of starch gelantinization, particle size, cellular form), and food form, as well as other food components (fat and natural substances that slow digestion—lectins, phytates, tannins, and starch-protein and starch-lipid combinations

CHILDREN AND ADOLESCENTS WITH DIABETES
Nutrition recommendations for children and adolescents with type 1 diabetes should focus on achieving blood glucose goals that maintain normal growth and development without excessive hypoglycemia. This can be accomplished through individualized food and meal planning, flexible insulin regimens and algorithms, self-blood glucose monitoring, and education-promoting decision-making based on outcomes. (8),(9)

Nutrient requirements for children and adolescents with type 1 or type 2 diabetes appear to be similar to other same age children and adolescents. Nutrition recommendations for youth with type 2 diabetes focuses on treatment goals to normalize glycemia and facilitate a healthy lifestyle. Successful treatment with nutrition therapy and physical activity can be defined as cessation of excessive weight gain with normal linear growth and achievement of blood glucose goals. Behavior modification strategies to decrease high-energy high-fat food intake while encouraging healthy eating habits and regular physical activity for the entire family should be considered (10).

WEIGHT MAINTENANCE:
Weight maintenance during height growth will create a relative weight loss that will allow satisfactory weight to be reached. Adolescents with no or limited height growth potential will need to lose absolute weight to decrease fatness. Remaining height growth potential can be determined by bone age assessment to identify degree of epiphyseal closure ( hand and wrist plain Xray). If BMI more than 95th percentile or obesity related comorbidities present the absolute weight loss is required.0.5-1 kg per month should be the achievable goal. Reduction in waist circumference could indicate loss of central fat.

LONG TERM COMMITMENT IS ESSENTIAL
Do not expect rapid changes.

DIET COUNSELING:
Age Specific diets and flexible (11):

1-5yrs: One of the most important things a parent can do is make sure their child eats a varied, balanced diet to meet the child’s high energy and nutrient needs. What children eat and drink during their early years can affect their health for many years to come. Poor nutrition during childhood can lead to increased risk of obesity, hypertension, diabetes and coronary heart disease in later life It is essential to offer a variety of foods from the four main food groups:

Fayth Clinic :