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 comorbidities 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.
Exclusion criteria
• 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.
Resources [1]
Growth charts
Growth charts and BMI charts can be downloaded and printed from the
RCPCH website.
• Growth charts
http://www.rcpch.ac.uk/growthcharts
• BMI chart
http://www.rcpch.ac.uk/system/files/protected/page/GIRLS%20and%20B
OYS%20BMI%20CHART.pdf
Resources [2]
Healthy eating – toddlers
The 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 toddlers
https://www.infantandtoddlerforum.org/c/document_library/get_file?uuid=224ed0
de-9017-4a81-8154-47eba1593671&groupId=11803
• Meals, snacks and drinks for toddlers
https://www.infantandtoddlerforum.org/c/document_library/get_file?uuid=ac042e
ba-f8fe-4cc8-9ee1-4be510506921&groupId=11528
• Portion sizes for Children 1-4 years
https://www.infantandtoddlerforum.org/c/document_library/get_file?uuid=ac042e
ba-f8fe-4cc8-9ee1-4be510506921&groupId=11528
Resources [3]
Healthy eating - teenagers
• Getting the balance right 11-16 years
http://www.teenweightwise.com/upload/kids/pdf/leaflets_english_getting
balance_11_16_bdang019.pdf
• Getting the balance right 16+ years
http://www.teenweightwise.com/upload/kids/pdf/leaflets_english_getting
balance_16plus_bdang020.pdf
• Eating out
http://www.teenweightwise.com/upload/kids/pdf/factsheets_english_eati
ngout_bdang005.pdf
• Packed lunches
http://www.teenweightwise.com/upload/kids/pdf/factsheets_english_pac
kedlunches_bdang006.pdf
• Quick, cheap and easy food
http://www.teenweightwise.com/upload/kids/pdf/factsheets_english_quic
kcheap_bdang007.pdf
• Quick recipe ideas
http://www.teenweightwise.com/upload/kids/pdf/factsheets_english_quic
krecipes_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 BMI
Negotiated 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?