Table 2, continued
Age group	Guidelines	Evidence
13–17 years 11 months	1. Conduct annual assessments of weight, height or arm span, and BMI. (see Supplemental File) 2. Consider monitoring other measures of adiposity, such as waist circumference. (see Supplemental File) 3. Conduct annual assessment of blood pressure/percentiles to monitor for pre-hypertension and hypertension. 4. Provide opportunities for teens and parents to talk about their priorities and concerns regarding nutrition and weight. – Discuss how nutrition can play an important role in helping individuals with spina bifida maintain a healthy weight, minimize skin breakdown, and increase activity and endurance. – Discuss that children with spina bifida, especially those who are non-ambulatory, who undertake low levels of physical activity, and who have higher body fat levels or contractures, are at increased risk for bone fractures. Recommend a diet with adequate calcium and vitamin D. – Provide regular opportunities for teens to discuss any concerns with their weight, growth, and diet. A trusting therapeutic relationship can greatly facilitate an honest and open discussion. – Identify the teen’s priorities and negotiate goals that meet those priorities as well as the parents’ and clinician’s goals. – Use a strengths-based approach that highlights their nutritional achievements and celebrates successes. – Discuss with families, if relevant, that the BMI is an imperfect indicator of health in all young people and especially those with spina bifida due to difficulties measuring height and body composition. Instead, show the family the trajectory of the child’s weight and height (or other measures of growth and adiposity) on a growth chart as a visual aid. Do not refer to growth cut-offs developed for typically developing children. A steeply increasing trajectory would indicate that overweight or obesity may be a concern and warrants preventative strategies. – Avoid using scare tactics in older children with spina bifida. Instead, discuss the following potential negative consequences of having higher weights, as it relates to their individual circumstances: * Moving and transferring may become more difficult, which may also reduce independence and self-care activities. * Increased pressure on the skin when seated for long periods of time (such as when using a wheelchair) may result in skin breakdown * Weight gain alongside existing scoliosis or kyphosis may result in additional breathing problems. – Refer clients to the National Center on Health, Physical Activity, and Disability (http://www. nchpad.org), which provides advice on nutrition and physical activity for persons with disabilities, including spina bifida. – Consider referral to a “Healthy Lifestyle” program and/or use a smartphone app, while recognizing that few such programs are tailored to individuals with disabilities. 5. Consider the broader literature for all older children, given that there is little evidence specifically for teens with spina bifida. For instance: – Understand that eating habits generally worsen as children move into the teen years and become more autonomous. – Emphasize the positive health benefits of breakfast and eating fruits and vegetables. Skipping breakfast and low fruit and vegetable consumption is common in teens. – Consider that food insecurity and lower socioeconomic status can be related to poorer diets. – Emphasize to parents that the family setting remains important for teens. Parental modelling, dietary intake, and encouragement are all associated with fruit and vegetable consumption among teens. 6. Discuss opportunities for the teen to participate in nutrition-related activities, such as: – Identify the teen’s knowledge level about healthy eating habits. – Encourage the family to identify roles that the teen can play as part of daily life, such as in meal planning, shopping, and food preparation. – Encourage teens to select a new healthy food to try, which can encourage broader food preferences. – Identify the older child’s existing strengths and resources regarding nutrition and how they can be built upon to reach their goals. 7. Screening for diabetes (fasting glucose, HbA1c or oral glucose tolerance test) every two years with a BMI $⩾$ 85${}^{\text{th}}$ percentile and have two or more additional risk factors including – family history of Type 2 Diabetes Mellitus (T2DM) in a first- or second-degree relative – high-risk ethnicity – acanthosis nigricans – hypertension – dyslipidemia – polycystic ovary syndrome	Clinical consensus as well as [3, 8, 12, 42, 43, 46–48, 67, 68, 74, 76, 77, 78, 81, 85–9]