Taryn BerryWeight Management Case Study

I. Understanding the Disease and Pathophysiology1. Current research indicates that the cause of childhood obesity is multifactorial. Briefly discuss how the following factors are thought to play a role in the development of childhood obesity: biological (genetics and pathophysiology); behavioral- environment (sedentary lifestyle, socioeconomic status, modernization, culture, and dietary intake); and global (society, community, organizational, interpersonal, and individual).

Biological: There is a clear link between obesity and genetics that has been found through many studies. Development of obesity has been seen to be a result in a susceptible genome present in a conducive environment. This means that putting a person that is susceptible to obesity in an obesigenic environment, which is a high-fat, energy-dense, and technologically advanced with little physical activity, results in obesity. Although we know it is genetic, it is hard to know which genes make someone susceptible, making obesity polygenic. One gene does not make one obese, but a multitude of gene variants work together in a susceptible environment contributes to obesity. At this time, genetic screening to find intervention and prevention are not available.

Behavioral-environment: Behavioral environment can immensely contribute to childhood obesity. When a child is in an environment that involves electronics, lack of physical activity, increased sedentary activities among friends, or an unsafe environment for exercise, a child is more susceptible to become obese. Socioeconomic status usually contributes to an unsafe environment outdoors, lack of parks, or toys, such as bikes. Modernization of technology has lead to a sedentary lifestyle among children. Electronics, such as iPads, video games, hand held games, and video games have led to children being less active then they have in the past. All of the above lead to an increased susceptibility of obesity.

Global: Looking at the big picture, when a group of children are sedentary together and have a lack of proper nutrition, they are not being thought a healthy lifestyle. Sedentary activities listed above become popular which leads to a society where physical activity and proper nutrition are not a priority. Also, within different countries, physical activity may or may not be accepted as much as others. This is also true for food, different cultures have different food preferences that may be higher in fat or calories.

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2. Describe health consequences associated with an overweight condition. Describe how these health consequences differ for an overweight versus an obese condition.

Health consequences associated with an overweight condition are Type 2 Diabetes, high blood pressure, abnormalities in LDL, HDL, VLDL, total cholesterol, non-alcoholic fatty liver disease, cancers, reproductive disorders,

and premature death. All these consequences are also associated with obesity, but at a larger scales. For instance, Type 2 Diabetes is two times as prevalent among obese people as compared overweight person. High blood pressure is also two times more common in obese patients then in overweight patients. Lipid levels are also more likely to be elevated in the obese population, which can lead to major risk factors for coronary heart disease. There is a six fold increase risk of systemic gallstones in a person who has a weight 50% what is recommended. Non-alcoholic fatty liver disease is more prevalent in these patients due to there increased central and abdominal fat. Some studies have linked obesity as a risk factor for cancer, especially in esophagus, colon, rectum, pancreas, liver, and prostate for men and gallbladder, bile duct, breast, endometrium, cervix, and ovaries in women. Reproductive disorders in men and women have been associated with obesity due to endocrine abnormalities. Lastly, studies have shown that the obese experience death sooner then lean people.

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3. Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea. Explain the relationship between sleep apnea and obesity.

Sleep apnea is a sleep disorder where breathing is repeatedly and briefly interrupted during sleep. The word “apnea,” refers to a breathing pause that can last 10 seconds or more during sleep. Obstructive sleep apnea is when the throat muscles in the back of the throat do not keep the airway open. According to the CDC, a 20-year study of disease related to obese children aged 6 to 17 years old found an increase of 436% were discharged for sleep apnea.

http://sleepfoundation.org/sleep-topics/obesity-and-sleep

II. Understanding the Nutrition Therapy4. What are the goals for weight loss in the pediatric population? Under what circumstances might weight loss in overweight children not be appropriate?

The goals for weight loss according to the Mayo Clinic, is based on age and if other medical conditions are present. Because she has been diagnosed with obstructive sleep apnea, weight loss is important for Missy’s well being. Weight loss should be slow and steady. It is suggested that weight loss should be 2 pounds a week to 1 pound per month, depending on the medical condition present. This goal should be met by commitment from the family to help the child eat a healthy diet and increase physical activity.

http://www.mayoclinic.org/diseases-conditions/childhood-obesity/basics/treatment/con-20027428

5. What would you recommend as the current focus for nutritional treatment of Missy’s obesity?

My current recommendations would be to switch to low fat or skim milk, low fat snacks that incorporate fruits and vegetables, and eliminating soda before bedtime.

III. Nutrition AssessmentA. Evaluation of Weight/Body Composition

6. Overweight or obesity in adults is defined by BMI. Children and adolescents are often-times classified as “overweight” or “at risk for overweight” based on their BMI percentiles, but this classification scheme is by no means universally accepted. Use three different professional resources and compare/contrast their definitions for overweight conditions among the pediatric population.

The CDC states that a child is considered overweight if they have a BMI greater then or equal to the 85th percentile and lower then the 95th percentile and greater the 95th percentile is considered obese on the growth chart. This compares children for the same age and sex.

The International Obesity Task Force provides BMI values that are categorized by age and sex for children ages 2-18 that are overweight and obese. A BMI >25 is considered overweight and a BMI >30 is considered obese.

The World Health Organization classifies infants and children ages birth to 5 as overweight if their BMI>2 standard deviations above the WHO growth median. For ages 5 to 19, a BMI>1 standard deviation above the WHO growth median is considered over weight.

http://www.cdc.gov/obesity/childhood/basics.html http://www.who.int/growthref/who2007_bmi_for_age/en/

7. Evaluate Missy’s weight using the CDC growth charts provided. What is Missy’s BMI percentile? How would her weight stats be classified by each of the standards you identified in question 6?

Weight: 115lb/(2.2kg/1lb)=52.27kg Height: 57in/(2.54in/cm)=144.78cm/100m=1.45m BMI=kg/m2

BMI=52.27/1.452=24.94 kg/m2

According to the growth charts provided and plotting the appropriate data points, Missy can be considered obese with a BMI of 25 because this is above the 97th percentile. According to WHO, Missy would be considered overweight with a BMI between 2 and 3 standard deviations on the WHO growth charts. According to the International Obesity Task Force, Missy is considered overweight with a BMI of 25.

B. Calculation of Nutrient Requirements8. If possible, RMR should be measured by indirect calorimetry. Identify two methods for determining Missy’s energy requirements other than indirect calorimetry and then use them to calculate Missy’s energy requirements.

Harris Benedict Equation:

655+(9.56 x wt(kg)) + (1.85 x ht(cm))-(4.68 x age(yrs)) 655+(9.56 x 52.27kg) + (1.85 x 144.78cm)-(4.68 x 10yrs)=1376 kcal EER Equation: (girls 3-18) (135.3-(30.8 x age(yrs))+PA x (10 x wt (kg)) + (934 x ht(m))) (135.3-(30.8 x 10) + 1.0 x (10 x 52.27kg) + (934 x 1.45m))=1704kcal http://www.eatrightks.org/2014_Conference_PDFs/Pediatric_ppt.pdf

C. Intake Domain

9. Dietary factors associated with increased risk of overweight are increased dietary fat intake and increased kilocalorie-dense beverages. Identify foods from Missy’s diet recall that fit these criteria. Calculate the percentage of kilocalories from each macronutrient and the percentage of kilocalories provided by fluids for Missy’s 24-hour recall.

Food/Drink Item Carbohydrates Fat Protein CaloriesIncrease Dietary Fat

2 Breakfast Burrito 55.6 13.9 19.2 424Bologna and cheese sandwich with mayo

54.2 22.7 17.7 498

Frito chips 17.9 8.1 1.7 1472 Twinkies 69.9 20 6.4 483Fried chicken-2 legs1 thigh

13.9 36.9 80.4 708

Fried okra 22.7 8 4.4 178Mashed potatoes 35.3 8.9 3.9 237Popcorn 20.9 10.9 3.6 190

Calorie Dense Beverages

Juice 14 0.2 0.1 57Whole milk 41 27.8 26.9 521Sweet tea 42.6 0 0.1 164Coca cola 35.2 0.1 0.3 136

Total: 423.2 157.5 164.7 3743Total for 24-hour Recall:

471.7 173.5 179.8 4134

Total Calories: 4134 kcal Carbohydrates: 471.7 g x 4kcal=1886.8kcal/4134kcal=45.6% Fat: 173.5g x 9kcal=1561.5kcal/4134kcal=37.8% Protein: 179.8g x 4kcal=719.2kcal/4134kcal=17.4%

10. Increased fruit and vegetable intake is associated with decreased risk of overweight. Using Missy’s usual intake, is Missy’s fruit and vegetable intake adequate?

No, Missy’s fruit and vegetable is far below adequate. She has no fruits or vegetables except for her apple juice at breakfast and the fired okra at dinner. Although, these are both high sugar and high fat ways of eating fruits or vegetables. With consideration of Missy’s 24-hour recall, she is not consuming enough fruits and vegetables on a daily basis. According to MyPlate, ¼ of your plate should be fruit and ¼ should be vegetables for every meal which is not true for Missy’s meals.

11. Use the MyPyramid Plan online tool (available from http://mypyramid.gov/; click on “MyPyramid Plan”) to generate a personalized MyPyramid for Missy. Using this eating pattern, plan a 1-day menu for Missy.

Breakfast: ½ c scrambled eggs, 1 wheat English muffin with 1 tbs butter, 8 oz orange juice

Snack: 8 baby carrots Lunch: Pita sandwich with turkey, cheese, lettuce, and mustard, ½ cup pretzels, 1 apple Snack: 8 oz vanilla yogurt and ½ c strawberries Dinner: Grilled chicken sandwich on a whole wheat bun, baked red skin

potatoes with ketchup, ½ cup broccoli, and 8 oz 1% milk.

12. Now enter and assess the 1-day menu you planned for Missy using the My Pyramid Tracker online tool (http://mypyramidtracker.gov/). Does your menu meet macro-micronutrient recommendations for Missy?

Total kcal: 2032 Carbohydrates: 287.4g x 4kcal=1149.6kcal/2032kcal=56.6% Fat: 53.3g x 9g=479.7kcal/2032kcal=23.6% Protein: 105.4g x 4kcal=421.6kcal/2032kcal=20.7% This would be a good diet for her to start off with so that her body gets used

to less energy consumption.

D. Clinical Domain13. Why did Dr. Null order a lipid profile and a blood glucose test?

Dr. Null ordered a lipid profile and blood glucose test to test for diabetes. With a strong family history of mother and grandmother having with 2 DM and possible gestational diabetes, there is a higher risk that Missy could develop diabetes. Testing blood glucose levels can allow Dr. Null to see insulin, glucagon, epinephrine, and cortisol are correctly controlling blood glucose levels. A malfunction with insulin production and secretion would make blood glucose increase. Seeing Missy’s lipid profile would allow Dr. Null to see if lipids are being metabolized and circulated in the blood properly. An increased amount of cholesterol could lead to future complications, such as heart complications.

Advanced Human Nutrition14. What lipid and glucose levels are considered to be abnormal for the pediatric population?

A glucose level over 100 mg/dL in children before puberty is considered high. For lipid levels, total cholesterol should be under 170 mg/dL, LDL cholesterol should be under 110 mg/dL, HDL cholesterol should be greater then 45 mg/dL, Apo A should be under 120 mg/dL, Apo B should be greater then or equal to 110 mg/dL, triglycerides should be under 90 mg/dL.

http://www.aacc.org/publications/cln/2012/March/Pages/LipidScreeningChildren.aspx#

15. Evaluate Missy’s lab results.Chemistry Normal Value Missy’s ValueAmmonia 9-33 umol/L 8 umol/L HDL-C >55 mg/dL 50 mg/dLHbA1c 3.9%-4.2% 5.5%According to the normal values listed in the table, the above values are abnormal. In question 14, I found contradictory values for some of the normal lipid and glucose values for children. I found that the glucose value should not be above 100 mg/dL but Missy’s glucose was 108 mg/dL. I also found that HDL should be >45 which would put her level in the normal range.

E. Behavioral-Environmental Domain16. What behaviors associated with increased risk of overweight would you look for when assessing Missy’s and her family’s diets?

I would assess the high fat and high calorie intake of their diet. I would try to figure out the reasoning for the food choices that they are currently making as a family. I would also look at her lack of fruits and vegetables, unhealthy snacking, high macronutrient intake, unbalanced meals, lack of whole grains, high caloric beverages, and caffeine before bedtime are behaviors related to diet that contribute to increased risk of overweight.

17. What aspects of Missy’s lifestyle place her at increased risk for overweight?

Missy’s lack of physical activity, attending a school that does not provide physical education, and sleep apnea are aspects of Missy’s lifestyle that place her at an increased risk of being overweight. These three things combined put negative stress on her body and contribute to her risk of being overweight.

18. You talk with Missy and her parents. They are all friendly and cooperative. Missy’s mother asks if it would help for them to not let Missy snack between meals and to reward her with dessert when she exercise. What would you tell them?

I would suggest that her high caloric snacks be replaced with low calorie snacks that incorporate fruits, vegetables, or low-fat dairy. Examples of this would be carrots and low-fat ranch dressing, apples and peanut butter, or low-fat yogurt and strawberries. I would not suggest to reward her with dessert when she exercises because this may lead to her over indulging and thinking that she should eat sweets every time she does something positive. This would lead to the development of more negative behaviors.

19. Identify one specific physical activity recommendation for Missy. I would suggest that she play outside with her friends after school if there is a

safe and close environment to do so. I would also suggest that her and her family take walks or bike rides if bikes and paths are available. Doing either of these three times a week would help increase physical activity with Missy and her family.

IV. Nutrition Diagnosis20. Select two high-priority nutrition problems and complete PES statements for each.

Excessive oral intake (NI-2.2) related to high caloric density and high fat foods as evidence by 24-hour recall.

Food and nutrition related knowledge deficit (NB-1.1) related to parents and child lack of education and general nutrition knowledge as evidence by conversation with patient and family.

V. Nutrition Intervention21. For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on etiology).

For the excessive oral intake PES statement, I would decrease her calories by 250 kcal per day. This will let her lose 0.5 lbs per week so that she loses 2 pounds per month till she is under the 95th percentile for weight.

For the nutrition related knowledge deficit, I would educate the family on high fat and high caloric foods. I would also suggest alternative food options that would help lower fat and calorie intake. Giving the family fun recipes that incorporate fruits, vegetables, and whole grains would be beneficial so that they go home with ideas. Lastly, I would show them food models to show current portion sizes versus what Missy should be eating.

22. Mr. and Mrs. Bloyd ask about using over-the-counter diet aids, specifically Alli (orlistat). What would you tell them?

I would explain what Alli diet aid is not recommended for children under the age of 18 or children aged 12 to 18 should advise their doctor. I would also tell them that vitamins A, D, E, and K are malabsorbed when taking Alli, which is important for a child Miss’s age. Also, Alli could strain her kidney because they are not fully developed and this a complex drug that changes the way the body absorbs fat. This could seriously harm the development of her organs.

http://www.obesityaction.org/educational-resources/resource-articles-2/medically-managed-weight-loss/alli-friend-or-foe

23. Mr. and Mrs. Bloyd ask about gastric bypass surgery for Missy. What are the recommendations regarding gastric bypass surgery for the pediatric population?

I would explain to Missy’s parents that gastric bypass surgery should be reserved if dieting and lifestyle changes do not seem to work. With her age being 10, her body is not fully developed so disrupting her body when it is still maturing could be potentially dangerous to growth and development of her body in the long-run. Weight loss surgery in pediatric patients is reserved for severely obese patients that cannot use conventional weight-loss methods or if there is a greater health threat involved with the child.

http://www.mayoclinic.org/diseases-conditions/childhood-obesity/basics/treatment/con-20027428

VI. Nutrition Monitoring and Evaluation24. When should the next counseling session with Missy be scheduled?

I believe that the counseling session should be 2 weeks after the initial session. I chose this time so that we make sure we stay on track and can discuss barrier and encourage improvements.

25. Should her parents be included? Why or why not? I believe that her parents should be included after I talk personally with

Missy. This will make sure that Missy shares her strengths and weaknesses with me before I talk to her parents. This would help make sure that Missy knows her goals then we can fill her parents in with what we talked about. Following this, I would talk to her parents about their concerns.

26. What would you assess during this follow-up counseling session? I would look at Missy’s food diary and physical activity log with her

personally. I would encourage her positive behavior and ask her if she needs help with any more changes to her lifestyle. I would do this by having her pick out things that she believes she did well and things that she thinks she needs to work on for both her diet and physical activity. Being positive will be very important because of her age. I would also look at the lab values that were abnormal and her weight and BMI. Next, I would asses her sleep log to see if she has improved on energy during the day and ability to sleep. Lastly, I would discuss improvements and barriers with her parents to make sure that we are moving in a positive direction.

References

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manuel: Dietetics Language for Nutrition Care. 2014. Retrieved from website: http://ncpt.webauthor.com/pubs/idnt-en/page-039

Center for Disease Control and Prevention. “Basics About Childhood Obesity.” 27 Apr 2012. Retrieved from http://www.cdc.gov/obesity/childhood/basics.html

Humenczuk, Margo. “Pediatric Nutrition Assessment.” Children’s Mercy, Kansas City. 25 Apr 2014. Retrieved from http://www.eatrightks.org/2014_ Conference_PDFs/Pediatric_ppt.pdf

Lofton, Holly F. “alli-Friend or Foe?” Obesity Action Coalition. Retrieved from http://www.obesityaction.org/educational-resources/resource-articles-2/medically-managed-weight-loss/alli-friend-or-foe

Mayo Clinic Staff. “Disease and Condition: Childhood Obesity.” 15 Feb 2014. Retrieved from http://www.mayoclinic.org/diseases-conditions/childhood-obesity/basics/treatment/con-20027428

Medeiros, D. M., & Wildman, R. E. (2015). Advanced human nutrition (III ed.).Burlington, MA: Jones & Bartlett Learning.

National Sleep Foundation. “Obesity and Sleep.” Retrieved from http://sleepfoundation.org/sleep-topics/obesity-and-sleep

Nelms, Sucher, Lacey, Roth. “Nutrition Therapy & Pathophysiology.” 2nd ed. Wadsworth. 2012.

Rollins, Genna. “Universal Lipid Screening In Children.” Clinical Laboratory News. V. 38, n.3, Mar 2012. Retrieved from http://www.aacc.org/publications/cln /2012/March/Pages/LipidScreeningChildren.aspx#

World Health Organization. “BMI-for-age (5-19 years)” Retrieved from http://www.who.int/growthref/who2007_bmi_for_age/en/