A. Specify general guidelines for an optimal diet consonant with pubertal growth in adolescence

• meal distribution + content
• nutrients needed
• alterations for athletes, vegetarians, pregnant adolescents

Mini-presentation with handouts
(such as Food Pyramid or meal guidelines)

Group discussion

Trainer gives a short presentation according to skill level of audience.

Group discusses how the growth processes of adolescence generate nutritional needs that differ from childhood and adulthood needs. Link the needs to the recommendations of the guidelines, generally and for the special cases under “alterations”. Indicate which recommendations are specifically related to the adolescent growth period (e.g. increased energy needs, sufficient calcium, vitamin D and iron intake) and which apply to all individuals but need repeating to adolescents because of their behaviour (e.g. the need for 3 main meals, prioritised complex carbohydrates and limited fast sugars).

Ref 1/Ch 6

Refs 2, 3, 4

Websites 1, 2

Discussion

Group work

In preparation for group work, class discuss the “dual-natured” impact of physical activities on physical health (endurance, resistance, lowered susceptibility to injury versus increased risk of injury); on psychological health (self-assurance vs. stress of training and performance); and on social health (group contact vs. social isolation due to restricted free time).

Group work suggestions:

1. List the major sports activities chosen by adolescents of the participants’ countries, and discuss the possible positive and negative impacts.
2. Based on a listing of different problems presented by teens, discuss which sport or physical activity could be recommended (e.g. for a back problem: swimming better than diving; for asthma: indoor activities during winter rather than outdoor activities; for hypertension: jogging or cycling better than weight lifting.)
3. Discuss the issue of the “female athletic triad” (bone density, menstrual disorder, eating disorder) and appropriate sport choices such as dancing or gymnastics.

C. Recognize the factors influencing attitudes and practices of adolescents and parents regarding diet and activity, including sedentary behaviours

• cultural, religious, socio-economical aspects
• adolescent- specific behaviours and concerns
• family influence

Readings

Small group work

Small group exercise:
Participants list lifestyle attitudes and behaviours in their countries that specifically impact food and activity habits. Which behaviours and attitudes appear to be particular to one country or group, and what may cause these? Which behaviours and attitudes seem to be common to adolescence across cultures (e.g. risk-taking, limit-testing)?

Note “sensitive” cultural/religious issues that a health practitioner may be confronted with (e.g. the wearing of an Islamic veil during sports or sharing showers after sports).

Module B7 for issues of under weight

Module A5

D. Describe and apply the methods used to calculate normal weight, excess or deficit, and to estimate fat distribution

• normal weight for height
• Body Mass Index
• waist-hip ratio
• definition of  obesity and underweight

Handouts (such as calculation methods, charts, definitions)

Class discussion

Discuss the strengths and limitations of each of the methods in relation to pubertal status.

Have the students calculate their waist-hip ratio, BMI, and weight for height; compare with curves and charts.

Discuss which information is most relevant for an adolescent patient, and how to obtain it (e.g. time and frequency of weighing).

Ref  1/Ch 33,

Refs 5, 6, 7, 8

E. Indicate key questions when taking history, and key findings at physical exam to be used in the assessment of diet, physical activity, fitness and self-perception in adolescent

• appropriate language
• timing/sequence of events in consultation
• adapt consultation to the patient’s reason for coming

Group work

Case studies

Role play

Case study: A 13 year-old girl involved in gymnastics, or a 16 year-old boy involved in body-building, comes to the outpatient clinic to have a sports club health certificate signed.

Case study: A 15 year-old girl who is training to be a beautician, and hoping to become a model, is dieting. Her mother is concerned and seeks your opinion.  
Take history and list key parameters of physical exam.

Role play: Two or three participants from a group can stage a case study to demonstrate the use of relevant questions and appropriate language in the consultation, as well as the timing and execution of an examination.

Module A3

Ref 1/Ch 6

Refs 9, 10

Reading

Mini-lecture

Class discussion

B. List the short-term and long-term risks of an inappropriate diet and insufficient activity in adolescence, with special attention to obesity

• growth and body functions
• diseases, comorbidity

Trainer provides the students with a list of deviations from normal diet (e.g. insufficient calcium, fiber or iron, or excess of saturated fat or simple carbohydrates, binge eating) and have them list the possible short-term and long-term consequences. Emphasize that most consequences are “silent or hidden” such as osteopenia, mild anemia, dyslipidemia and glucose intolerance, or “delayed” such as increased incidence of colon cancer, atherosclerosis and diabetes.

Briefly mention the rising incidence of Type 2 diabetes. What is the incidence in the countries represented by the participants?

Class “brainstorm” strategies, listing them as either natural (e.g. meal content) or artificial (e.g. pain maskers). Refer to case examples, and construct other examples. Discuss the strategies and their limits of safety; What promotes the use of these different strategies? (A detailed discussion of doping is not a goal here.)

Case examples:

1. A highly ambitious 16 year-old boy appears to be over exerting himself at a local health club. He has bought many different body-building supplements, and may be considering doping.
2. An adolescent involved in judo at the international level has received vitamin prescriptions from the coach. He is convinced that supplements are needed to reach the top level of fitness.

Participants: Explain the possible consequences of inappropriate diet and activity on chronic conditions such as diabetes, asthma and cystic fibrosis.

Trainers: Highlight how variable the spectrum of consequences can be depending on the disease and its management.

E. Select and obtain the information needed in the assessment of an obviously obese adolescent

• risk factor history
• secondary causes
• comorbidity
• psychological status-additional assessment procedures

Case study

The divorced mother of a 15 year-old boy who is 50% overweight comes to your clinic because she feels concerned about the weight of her son who does not care and did not want to come.  She thinks the boy eats too many sweets and fast food during his weekend visits with his father. There appear to be several conflicting issues involved.

When taking the history, which questions should be asked to whom?
How would you perform the physical exam? List the additional procedures of assessment you would consider, and give the rationale for these. What do you propose to the adolescent and to his mother?

Class discussion

Role play

Simulated patients

Among the adolescents attending an outpatient clinic and having significant obesity, only about half of them complain about weight. Identify reasons why an adolescent with abnormal weight, nutrition, and/or activity habits may not complain specifically about these. How might overweight be disguising other problems? List reasons why and how a parent may be an impediment to assessment and communication. Consider how provider bias may affect the situation.

Role play the case study in Goal II, objective E, talking with the mother and her obese 15 year-old son. What factors may contribute to making this conversation difficult? How would the dynamics of this case study change if the mother would also be overweight?

A. Select among the possible interventions those appropriate for overweight adolescents in a multidisciplinary setting

• education
• diet and activity
• medications
• surgery
• psychological counselling
• “wait and see”

Class discussion or small group work with plenary review

Example of a program

Class/groups discuss what are the pros and cons of each intervention strategy listed at left when applied to adolescents in general. What are the medical or ethical considerations?  What factors will affect the final choice for an individual patient? Note that the adolescent’s input is a factor in compliance.

Issue: What are the rationale for and the practicability of a “multidisciplinary approach” to obesity?

Case study: A grossly obese 16 year-old girl who has already seen three dieticians and a couple of doctors comes to the private practice. Discuss the choice of treatment for this obese adolescent and how to optimally design a multidisciplinary management.

B. Prioritise the intervention choices for an adolescent, considering the factors that may interfere with the management of nutritional or activity disorders

• biological considerations
• motivational, psychological context
• environmental factors, family eating habits, lifestyle
• peers and family opinion

Briefly review several case situations and discuss:

1. if  and when exceptional treatment such as long term hospitalisation or gastric by-pass should be considered, and
2. if and how to involve or not to involve the family or peers in the different interventions with an obese adolescent (planning diet, promoting physical activity, providing support, and counselling).

Case examples

1. A 15 year-old who is mildly retarded weighs 140 kg and has complications (type 2 diabetes, joint injuries, hypertension and breathlessness during moderate exercise). His parents are obese, not supportive, and had gastric bypass surgery. They want the same for their son.
2. A moderately obese 14 year-old girl lives in a boarding school during the week, and spends weekends with her grandparents. Her mother and father are divorced.

Small group discussion and role play

Invited adolescents

Discuss simple techniques and tricks to assist the adolescent adhere to a diet (food diary, item replacement, self-monitoring, nutrition and “fast food”, behaviour modification tips, websites). Use the Activity Pyramid to discuss daily activity needs with an adolescent.

How do you communicate with an adolescent who is fanatic about sports achievement and may be engaging in harmful behaviour? How do you deal with the case of a coach or sports physician who prescribes a regime or substance you do not agree with?

Select one or more of the “sensitive” cultural/religious issues identified by participants in Goal I, Objective C, and role play counselling an affected adolescent on healthy life style choices for eating and activity.

Self-reflection exercise: Examine the influence of one’s own professional background and experience on one’s attitude about weight and lifestyle.For example, what would be the significance to you and to your patient of prescribing thyroxine (substitution doses) or metformin in a euthyroid euglycemic obese adolescent?

Group discussion:

Recent studies have shown that physicians counsel only 29% of overweight patients and fail to participate in the primary prevention of overweight and obesity (American Medical Student Assoc.). What personal factors, including having previous unsuccessful cases, are likely to interfere with treating weight problems professionally? Share and discuss the results of the self-reflection exercise. What are the reactions to hearing that there is no evidence-based successful weight loss strategy to date? How do the participants feel when faced with the powerful marketing of “junk food”, and the popularity of immobilizing pastimes?

Case study

A secondary school director is concerned by the increasing incidence of obesity among the students. You are asked to examine the possible contributing factors.

Relevant issues: access to sports facilities, parental support, shops and “fast foods” in the neighbouring area, snacks and soda drinks available at school, information to students, food and activities available at lunch break.