Kaitlyn Click Professor Matuszak KNH 41114 October 2014

Case Study 1 Weight Management

I. Understanding the Disease and Pathophysiology

1. 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-environmental (sedentary lifestyle, socioeconomic status, modernization, culture, and dietary intake); and global (society, community, organizational, interpersonal, and individual).

Childhood obesity is a rising issue that has become a major health crisis. Obesity is due to an imbalance between caloric intake and the calories utilized for activities. Additionally, it also is multifactorial. Biological factors, behavioral-environmental factors, and global factors all may have a role in this. First, biological factors, such as genetics, may lead to childhood obesity. Genes can increase the child’s susceptibility and, therefore, impact the metabolism accordingly. If a child’s parents have genes of obesity, the child may have a greater risk. Secondly, behavioral factors can play a role in the development of childhood obesity. Regarding a child’s dietary intake, if they consume large portions and more energy than they utilize, it may lead to weight gain. Also, if a child is consuming foods that are high in sugar and fat, they are more likely to gain weight as well. Lack of physical activity is a risk factor of childhood obesity as well. Many kids these days enjoy video games and the TV over running around outside. There is also an unhealthy link between eating and watching TV at the same time. If a child is eating while engrossed in a television show, they are more likely to eat larger portions than they normally would. Commercial advertisements also promote unhealthy food choices in an appealing way for children. This becomes a vicious cycle of overconsumption of unhealthy foods paired with a sedentary lifestyle. This is not only a risk in the home, but also at school and in the community as well. When a child is at home, the parents play a huge role in promoting a healthy lifestyle. At school, children are influenced by their peers and also the atmosphere, food provided, and healthy lifestyle promotion of the school inside and outside of the classroom. The community that the child lives in can also be a huge factor. For example, accessibility of healthy food options, affordability of those options, or lack of facilities like side walks and parks can impact whether or not the child is eating well and staying active. The community is especially important because it can impact the family at home and also the schools. By having a health-conscious community, there is more awareness and intervention toward providing a safe, active, and healthy atmosphere.

Karnik, S., & Kanekar, A. (2012, January 1). Childhood obesity: A global public health crisis.

Retrieved October 12, 2014, from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278864/

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

There are many severe health concerns associated with the overweight condition. Some of these consequences include coronary heart disease, high blood pressure, stroke, type 2 diabetes, abnormal blood fats, metabolic syndrome, cancer, osteoarthritis, sleep apnea, and gallstones. CHD is when plaque builds up inside of the coronary arties and cuts off the blood supply to the heart, causing narrow or blocked arteries, chest pain, heart attack or even heart failure. High blood pressure is when the force of the blood in the arteries elevates to an unhealthy degree. Stroke occurs when plaque in the arteries forms a blood clot, which has potential of blocking oxygen and blood flow to the brain. Type 2 diabetes is when blood glucose levels are too high because the body is not able to break down the food to glucose and use the hormone insulin to turn glucose into energy properly because the body lacks the ability to make enough insulin. Abnormal blood fats are high levels of triglycerides and LDL cholesterol and low levels of HDL cholesterol. Metabolic syndrome is having at least three of a list of risk factors that increase your risk of developing other health problems. Some of these risk factors include a large waistline (abdominal obesity), abnormal blood fats, high blood pressure, and high fasting blood sugar. Cancers such as colon, breast, gallbladder, and endometrial cancers are a higher risk. Osteoarthritis is a joint issue in the hips, knees, and lower back and happens when the protective tissue on the joints deteriorates. Extra weight can cause more pain on the joints. Sleep apnea is when there are one or more pauses in breathing during sleep or having shallow breathes. This happens when there is extra fat around the neck area. Gallstones are hard pieces that form in the gallbladder, made mostly of cholesterol, which can cause back pain or stomach pain. The difference between the overweight and obese condition with these health consequences is that as the BMI increases (going from overweight to obese), there is a greater risk and chance of facing these issues and a greater chance that they will be more severe. The BMI for overweight is 25.0-29.9 kg/m2, while the BMI for obese is 30.0-39.9 kg/m2. For children, it is a little different. For kids ages 2-19, their BMI is plotted on a standard growth chart. A child is considered overweight if they fall at the 85th and below the 95th percentile. They are considered obese with a BMI at or above the 95th percentile. Children may also face different health consequences having to do with their mental health as they are still growing into themselves. Aside from the medical problems such as high blood pressure, high cholesterol, abnormal lipid level, insulin resistance, type 2 diabetes, shortness of breath, sleep apnea, delayed maturity, and liver and gallbladder disease, children also face the increased risk of eating disorders, depression, and substance abuse. Health consequences as a child also create a greater concern and risk for the patient as an adult.

Gavin, M. (2012, October 1). Overweight and obesity. Retrieved October 12, 2014, from

http://www.kidshealth.org/parent/general/body/overweight_obesity.html

What are the health risks of overweight and obesity? (n.d.). Retrieved October 12, 2014, from

http://www.nhlbi.nih.gov/health/health-topics/topics/obe/risks.html

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

Click 2

Sleep apnea is a sleep disorder when breathing pauses for at least ten seconds repeatedly. This condition occurs when the muscles in the throat cannot keep the airway open to breathe. This can cause low blood oxygen levels and interrupted sleep patterns. These issues alone can then lead to high blood pressure, heart disease, mood swings, and memory problems. There is a positive correlation between sleep apnea and obesity, and is especially serious among children. If there is extra weight around the neck and truck area, it becomes harder for those muscles to do their job and open the airway effectively. If the individual is experiencing disrupted sleep and sleepiness throughout the day from it, they may then become less motivated and likely to engage in physical activity or healthy eating patterns. Therefore, sleep apnea has the potential to create a dangerous cycle. Additionally, sleep deprivation has been shown to actually increase appetite. The body can confuse signs and feelings of fatigue and hunger. Without proper intervention and treatment, this condition can become very serious and detrimental to the patient’s health and quality of life.

Sleep apnea. (n.d.). Retrieved October 12, 2014, from http://sleepfoundation.org/sleep-disorders-

problems/sleep-apnea

Obesity and sleep. (n.d.). Retrieved October 12, 2014, from http://sleepfoundation.org/sleep-

topics/obesity-and-sleep

II. Understanding the Nutrition Therapy

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

For children and adolescents that have stopped growing, the general goals for weight loss include modifications to diet and increasing physical activity. Children under the age of seven are not recommended to make these modifications for weight loss yet because their bodies are still changing and developing. The goal for this population is to maintain their weight. For children over the age of seven, the initial goal is to maintain a weight while starting to make gradual changes in their eating and physical activities with supervision from a professional. These patients should work on lowering their fat intake (DRI: 30-40% kcal in children 1 to 3 years old, a reduction to 25-35% in children 4 to 18 years old) and sodium intake and increasing their variety of foods and fruits and vegetables. A carbohydrate intake of 45-65% kcal is recommended for children and adults, while a protein intake of 5-20% kcal is recommended for children 1 to 3 years old and 10-30% kcal in children 4 to 18 years old. Small changes such as fewer cookies or soda drinks and switching from whole milk to skim milk and low-fat dairy options can make a big difference. Parents also have a role in the goals of their child for weight loss. They can be supportive, inclusive in family mealtime, avoid using food as a reward, and provide healthy food choices. The parents can also be educated on healthier ways to prepare foods (i.e. avoid frying). The child is more likely to follow the example of their parents so getting the whole family involved in the goals of the patient can be successful. Furthermore, goals for treatment of overweight children are based on their age, degree of overweight, and their

Click 3

comorbidities. If the child has comorbidities, their weight loss goals are individualized. Otherwise, potential goals for weight loss include maintenance of BMI and then gradual weight loss of 1 to 2 kg/mo. Older adolescents who have completely stopped growing linearly may require more intense weight loss goals similar to adults. The five guiding principles for weight loss in this population are: 1) establish individuals goals, 2) involve the family in these goals, 3) assess and monitor often, 4) recognize the behavioral, psychological, and social factors that correlate to potential weight gain, and 5) provide intervention for diet changes and increasing exercise.

Daniels, S., Arnett, D., Eckel, R., Gidding, S., Hayman, L., Kumanyika, S., ... Williams, C.

(n.d.). Overweight in children and adolescents. Retrieved October 12, 2014, from

http://circ.ahajournals.org/content/111/15/1999.full

Weight management. (n.d.). Retrieved October 12, 2014, from

http://www.stanfordchildrens.org/en/topic/default?id=weight-management-and-

adolescents-90-P01626

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

After reviewing Missy’s current data and lab results, I think the focus for her nutritional treatment should be to maintain her weight and slowly make changes in her lifestyle to lose weight in a healthy way. One of the main concerns with Missy is her sleep apnea, which is being caused by her current weight of 115 lbs. Since Missy is only ten years old, she is still growing and changing. However, since she is over seven, I think small steps would be appropriate to implement in her lifestyle and make healthy changes. I believe Missy and her parents would benefit from being educated about ways to improve her diet and choose healthier food options. They should be instructed on how to choose foods with less fat, sugar, and sodium, as well as the importance of fruits and vegetables in her diet. By doing so, they should start to see a change in her overall wellbeing. Right now, her mood and happiness is being compromised by her inability to get a good night sleep. With appropriate nutritional treatment, Missy should hopefully start to sleep better and be more attentive during the day. Missy and her family should also be counseled on appropriate portions for a child her age and the break up of macronutrients in her meals. A helpful tool would be MyPlate. With making these changes, her lab values should also stabilize. Many values are normal but approaching the border to unhealthy. Her glucose, sodium, LDL, and HDL should be focused on in particular.

III. Nutrition Assessment

A. Evaluation of Weight/Body Composition

Click 4

6. Overweight or obesity in adults is defined by BMI. Children and adolescents are oftentimes 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.

Professional Resource Definition for Childhood OverweightWorld Health Organization (WHO) “WHO Child Growth Standards (birth to age

5): Overweight: BMI >2 standard deviations above the WHO growth standard median”

“WHO Reference 2007 (ages 5 to 19):Overweight: BMI > 1 standard deviation above the WHO growth standard median”

US Centers for Disease Control and Prevention (CDC)

“CDC Growth ChartsIn children ages 2 to 19, BMI is assessed by age- and sex- specific percentiles:Overweight: BMI >85th percentile and <95th percentile”

International Obesity Task Force “Provides international BMI cut points by age and sex for overweight and obesity age 2 to 18”“The cut points correspond to an adult BMI of 25 (overweight) or 30 (obesity)”

These three professional organizations have different definitions for what it means to be overweight in the pediatric population. The WHO has much higher BMI cut points for overweight, for example, than the International Obesity Task Force for a young girl because the International Obesity Task Force uses adult BMI cut points. Also, the CDC says that a normal weight range for older adolescents includes BMIs greater than 25 and overweight greater than 30. If these BMIs were continued into adulthood, a few years later, the “normal” range would be overweight while the overweight range would be obese. Also, these definitions use different forms of language such as “percentile” versus “standard deviations”. The WHO and CDC have similar ideas using the growth charts/standards for children. However, these organizations should standardize their language and meanings of the definition for a better understanding of the general public.

Defining childhood obesity. (n.d.). Retrieved October 12, 2014, from

http://www.hsph.harvard.edu/obesity-prevention-source/obesity-definition/defining-

childhood-obesity/

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

Click 5

Weight: 115 lbs/2.2= 52.3 kg

Height: 57 in x 0.0254= 1.45 m x 1.45 m= 2.1 m2

BMI= kg/m2

= 52.3/2.1 =24.9 kg/m2

Using the CDC growth charts provided, Missy is approaching the 90th percentile for stature-for-age, she is above the 90th percentile for weight-for-age but still below the 97th percentile, and she is above the 97th percentile for BMI-for-age.

Her BMI percentile put her in the “obese” category, according to the CDC.

Missy’s weight status would be considered obese according to the World Health Organization as well. Missy’s weight status would be normal (approaching overweight) according to the International Obesity Task Force.

BMI-for-age (5-19 years). (n.d.). Retrieved October 12, 2014, from

http://www.who.int/growthref/who2007_bmi_for_age/en/

B. Calculation of Nutrient Requirements

8. 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.

Two methods for determining Missy’s energy requirements other than indirect calorimetry are 1) Estimated Energy Requirements (EER) and 2) Total Energy Expenditure (TEE). Both of these methods are calculated taking her age and sex into consideration (females ages 9 to 18 years for EER and 3 to 18 for TEE) and the TEE, specifically, takes her overweight/obese condition into consideration as well.

Weight: 115 lbs/2.2= 52.3 kg

Height: 57 in x 0.0254= 1.45 m

Estimated Energy Requirements for Females Ages 9 to 18: EER= 135.3 – 30.8 x age + PA x (10.0 x weight + 934 x height) + 25PA=1.00 for sedentary

Click 6

EER= 135.3 – 30.8 x 10 + 1.00 x (10.0 x 52. 3 kg + 934 x 1.45 m) + 25 = 1729.6 kcal = ~1700-1750 kcal

Total Energy Expenditure for Overweight Females Ages 3 to 18: TEE= 389 – 41.2 x age + PA x 15.0 x weight + 701.6 x height PA= 1.00 for sedentary

TEE= 389 – 41.2 x 10 + 1.00 x 15.0 x 52.3 kg + 701.6 x 1.45 m = 1778.8 kcal = ~1750-1800 kcal

(Nelms, Sucher, Lacey, Roth, p. 242-243)

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.

Missy’s 24-hour recall:

AM 2 breakfast burritos, 8 oz whole milk, 4 oz apple juice, 6 oz coffee with ¼ c cream and 2 tsp sugar

Lunch 2 bologna and cheese sandwiches with 1 tbsp mayonnaise, 1-oz pkg Frito corn chips, 2 Twinkies, 8 oz whole milk

After-school snack

Peanut butter and jelly sandwich (2 slices enriched bread with 2 tbsp crunchy peanut butter and 2 tbsp grape jelly), 12 oz whole milk

Dinner Fried chicken (2 legs and 1 thigh), 1 c mashed potatoes (made with whole milk and butter), 1 c fried orka, 20 oz sweet tea

Snack 3 c microwave popcorn, 12 oz Coca-Cola

Increased dietary fat: breakfast burritos, bologna and cheese, mayonnaise, Frito corn chips, Twinkies, whole milk, fried chicken, the butter and whole milk in the mashed potatoes, fried orka

Increased Kilocalorie-Dense Beverages: whole milk, cream in the coffee, sweet tea, Coca-Cola

Breakdown of Missy’s 24-hour Recall using Fitday:

Food Amount Calories Fat (g) Carbohydrates (g)

Protein (g)

Breakfast burritos

2 burritos 424 14 56 19

Click 7

Whole milk 8 oz 146 8 11 8Apple juice 4 oz 58 0 14 0Coffee 6 oz 2 0 0 0Cream ¼ cup 78 7 3 2Sugar 2 tsp 33 0 8 0Bologna and Cheese Sandwich

2 sandwiches 693 39 59 27

Mayonnaise 2 tbsp 198 22 1 0Frito corn chips

1 oz 139 6 18 3

Twinkies 2 twinkies 302 5 62 3Whole milk 8 oz 146 8 11 8Peanut butter 2 tbsp 188 16 6 8Grape jelly 2 tbsp 101 0 27 0Enriched bread

2 slices 138 2 26 4

Whole milk 12 oz 204 11 15 11Fried chicken 2 legs, 1

thigh419 25 0 46

Mashed potatoes

1 cup 210 7 33 4

Fried orka 1 cup 173 13 13 2Sweet tea 20 oz 121 0 31 0Microwave popcorn

3 cups 138 9 15 3

Coca-cola 12 oz 153 0 39 0Totals: 4065 190.9 449.3 148.0

(Fitday.com)

Macronutrient Breakdown:

Fat: 190.9 g x 9 kcal/g = 1718.1 kcal1718.1 kcal/4065 kcal = 0.42342.3%

Carbohydrates: 449.3 g x 4 kcal/g = 1797.2 kcal 1797.2 kcal/4065 kcal = 0.44244.2%

Protein: 148.0 g x 4 kcal/g = 592 kcal 592 kcal/4065 kcal = 0.14614.6%

Click 8

Breakdown of Fluids (percentage of kilocalories provided by fluids):

Liquid Amount Calories Fat (g) Carbohydrates (g)

Protein (g)

Whole milk 28 oz 496 27 37 27Apple juice 4 oz 58 0 14 0Coffee 6 oz 2 0 0 0Cream ¼ cup 78 7 3 2Sweet tea 20 oz 121 0 31 0Coca-cola 12 oz 153 0 39 0

Totals: 908 34 124 29

908 kcal/4065 kcal= 0.22322.3%

Food log. (n.d.). Retrieved October 12, 2014, from http://www.fitday.com/app/log/foods

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?

According to Missy’s 24-hour recall, her fruit and vegetable intake is inadequate. The only fruit sources she is getting are apple juice and grape jelly. Both of these are not good sources of fruit unless the apple juice was 100% juice, which was not specified. Subsequently, the only vegetables she ate were orka and mashed potatoes. These too were not good sources of vegetables because the orka was fried and she lacks greens in her diet, which carry many more nutrients than mashed potatoes. The USDA recommends that girls ages 9 to 13 should be getting at least 1 ½ cups of fruits and at least 2 cups of vegetables. Missy may even benefit from more than the recommended servings a day. ChooseMyPlate provides educational materials about appropriate portions of food groups and examples of different kinds of foods that fit into each category.

Choose a food group. (n.d.). Retrieved October 12, 2014, from

http://www.choosemyplate.gov/food-groups/

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

According to Missy’s individualized food plan centered on her age, height, and activity level, and based on a 1600-calorie diet, she should be consuming 5 ounces of grains, 2 cups of vegetables, 1.5 cups of fruits, 3 cups of dairy, and 5 ounces of protein foods. She should aim to make half of her grains whole (so about 3 ounces), vary her vegetables, and avoid oils and empty calories as much as possible.

Click 9

Missy’s 1-Day Menu:

Breakfast: 1 slice of whole-wheat toast, 1 tsp unsalted butter, 1 scrambled egg, 8 oz orange juice

Mid-morning snack: 1 cup fat-free vanilla yogurt, ½ cup strawberries, ¼ cup granola, 4 oz water

Lunch: 8 oz skim milk, 2 oz of grilled chicken, ½ cup of unsweetened applesauce, 1 cup green beans

Afternoon snack: 1 cup of carrots with 2 tbsp hummus

Dinner: 8 oz skim milk, 2 oz lean hamburger meat, 2 whole wheat buns, 1 slice of tomato, 1 slice of low-fat cheddar cheese, 1 leaf of leattuce, ½ cup of corn

Evening snack: 1 cup of multi-grain pretzels, 4 oz water

Daily food plan. (n.d.). Retrieved October 12, 2014, from

http://www.choosemyplate.gov/myplate/index.aspx

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

Food Details Report:

Click 10

Protein: 27% of kcalCarbohydrate: 58% of kcal Fat: 18% of kcal

Reports on Macronutrients:

Click 11

Reports on Nutrients/Micronutrients:

Click 12

According to the reports supplied by Super Tracker (shown above), my 1-day menu for Missy provides slightly over the recommended food group goals. My menu supplies her with 2 ¾ cups vegetables, 5 ½ ounces of grains, 2 ½ cups of fruit, 3 ½ cups dairy, and 5 ounces of protein foods. While these amounts are slightly higher than recommended, I think it is OK to have her fruits and vegetables in higher amounts because an increase in these is linked to a decrease in overweight. I used grilled instead of fried foods and low fat or skim instead of higher fat dairy options. I also added whole grains to her menu and healthier snacks. If I were to modify this current plan, I would fortify the drinks because my current menu is slightly low in some vitamins (Vitamins D, E, and K). Also, I might add a banana as a snack food because her menu is slightly low in potassium. Besides those changes, this menu could be an appropriate tool for Missy to use.

Supertracker. (n.d.). Retrieved October 12, 2014, from

https://www.supertracker.usda.gov/foodtracker.aspx

D. Clinical Domain

13. Why did Dr. Null order a lipid profile and a blood glucose test?

Dr. Null ordered a lipid profile and a blood glucose test to check for any abnormalities. The lipid profile tested HDL cholesterol level, LDL cholesterol level, the ratio of HDL and LDL, and triglyceride level, most notably. The blood glucose level test was done to check fasting glucose, increased plasma insulin values, and glucose tolerance, associated with Type 2 diabetes. An abnormal lipid profile would suggest dyslipidemia, while an abnormal glucose test could suggest diabetes or hyperinsulinemia. Overweight and hyperinsulinemia are both associated with one another and the two are also related to dyslipidemia. Furthermore, these tests could indicate metabolic syndrome as well. If Dr. Null is able to identify metabolic syndrome early on, there is a better chance for preventing more chronic diseases later on in Missy’s life. Metabolic syndrome can lead to many other health complications such as CVD, atherosclerosis, or Type 2 diabetes. Since overweight is the key component in children, it is important to perform necessary tests for thoroughly checking to see if Missy may have metabolic syndrome. The American Heart Association suggests that blood glucose testing be done if the patient has risk factors such as overweight and family history and testing should begin at the age of 10 years or when puberty starts. Children with family history of CVD or parental hypercholesterolemia should have a lipid profile done as well as testing for hypertension. Missy is both overweight with family history of diabetes (mother, most directly) and has family history of heart attack and high blood pressure.

Jessup, A., & Harrell, J. (n.d.). The metabolic syndrome: Look for it in children and adolescents

too. Retrieved October 12, 2014, from

http://clinical.diabetesjournals.org/content/23/1/26.full

Click 13

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

As previously stated, the lipid levels of concern for the pediatric population are mainly low HDL, high LDL, high LDL/HDL ratio, total cholesterol, and high triglycerides. The glucose levels of concern are glucose and HbA1C, which measures diabetes management or average blood sugar over several months. The reference ranges of a lipid profile and glucose test are as follows:

Lipid Levels Reference RangeCHOL 120-199 mg/dLHDL >55 mg/dLVLDL 7-32 mg/dLLDL/HDL ratio <3.22TG 35-135 mg/dLGlucose LevelsGlucose 70-110 mg/dLHbA1c 3.9-5.2%

HbA1c. (n.d.). Retrieved October 12, 2014, from

http://www.ucsfbenioffchildrens.org/tests/003640.htm

15. Evaluate Missy’s lab results.

Lipid Levels Reference Range 11/20CHOL 120-199 mg/dL 190HDL >55 mg/dL 50VLDL 7-32 mg/dL 30LDL/HDL ratio <3.22 2.2TG 35-135 mg/dL 114Glucose LevelsGlucose 70-110 mg/dL 108HbA1c 3.9-5.2% 5.5

Missy’s lipid profile is currently normal, however, if she continues with her eating habits and sedentary lifestyle, those values can quickly become abnormal since they are approaching the border already. Her blood glucose test, on the other hand, suggests that Missy may be developing Type 2 diabetes. Her glucose levels are normal but approaching the border, and her HbA1c is slightly high.

E. Behavioral-Environmental Domain

16. What behaviors associated with increased risk of overweight would you look for when assessing Missy’s and her family diets?

Click 14

When assessing Missy’s and her family’s diets, there are several behaviors I would look for. First, I would see how her parents handle mealtime and food. Do they use food as a reward? Do they eat in front of the television? Do they sit down as a family to eat dinner? Do they involve Missy in the meal prep? These are a few examples of the behaviors surrounding food that I would check on. They should not be rewarding Missy with food or eating in front of the television. They should sit down as a family to eat and involve Missy in meal prep. Secondly, I would look at their diets in particular. Diets high in saturated fat, sugar, and sodium are associated with an increased risk of overweight. Methods of cooking such as frying instead of grilling or baking can also contribute to an unhealthy diet. Thirdly, I would see if they consume high-calorie beverages. Beverages high in calories and/or sugar are extra, empty, and unneeded calories that contribute to overweight as well. Lastly, I would look to see what portions Missy’s parents are consuming. Missy’s 24-hour recall shows that she is consuming big portions of unhealthy food choices. I would want to see how her and her parent’s diets match up and then put them all on a healthier eating plan to work toward Missy’s goals together.

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

Missy’s current lifestyle places her at an increased risk for overweight. First, she reports that her hobbies are playing video games and reading. These two activities require very little movement and energy. Secondly, Missy’s elementary school discontinued their physical education class due to budget cuts. Therefore, Missy is neither getting exercise at home or at school. Ten year olds especially should enjoy running around and engaging in physical activities. Thirdly, Missy suffers from sleep apnea, which makes her tired, moody, unfocused, and unmotivated throughout the day. All aspects of her life intersect and affect her quality of life. Since she has a poor diet, she has gained weight, which has caused her sleep apnea and consequently, her lack of motivation to be active.

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 exercises. What would you tell them?

I would tell Missy’s parents that, first, snacking between meals can actually be healthy if done right. If they provide Missy with a healthy, nutrient-dense snack when she is hungry between meals, she will be less likely to over-eat during mealtime. Snacks between meals is also a way to keep Missy’s energy up since she is oftentimes tired from her sleep problems at night. Secondly, I would tell them that they should not reward Missy with dessert after she exercises. There are a few reasons for this. While it seems like an effective strategy, it may actually send mixed signals to Missy. If Missy is trying to learn what healthy foods she should be eating and what unhealthy foods she should avoid, it can be confusing to offer unhealthy foods as a reward. Also, she may unknowingly start to associate the unhealthy desserts with a “good mood”. This can encourage, for example, wanting desserts in the future when she feels good. Furthermore, desserts are very sugary and could cause cavities and unwanted weight gain while other progress is being made. I would encourage, instead of a food reward, to reward Missy with an alternative such as more reading time at night before bed or a trip to the library.

Click 15

Why parents shouldn't use food as a reward or punishment. (n.d.). Retrieved October 12, 2014,

from http://www.urmc.rochester.edu/encyclopedia/content.aspx?

ContentTypeID=160&ContentID=32

19. Identify one specific physical activity recommendation for Missy.

One recommendation I would make regarding physical activity for Missy and her family would be to become members at a their local gym or YMCA-like facility. Not only would this encourage the whole family to be active together but it would also get Missy out of the house where her sedentary hobbies restrict her. I would recommend the family go to the facility 3-5 times a week to start and engage in family physical activities (walking around the track, dribbling a basketball, kicking a soccer ball, tennis, swimming, etc.). The wide variety of activities that a facility offers may spark an interest of a new hobby for Missy that she will enjoy. Her and her family should go for a minimum of 30 minutes at a time and explore their interests together. Also, seeing other members be active and enjoy themselves may motivate Missy to get involved as well.

IV. Nutrition Diagnosis

20. Select two high-priority nutrition problems and complete PES statements for each.

PES #1: Excessive energy intake (NI-1.3) related to high intake of calories, fat, and calorie-dense beverages as evidenced by 24-hour recall of 4065 kcal.

PES #2: Physical inactivity (NB-2.1) related to sedentary lifestyle as evidenced by patient self-report of activity during the day, favorite hobbies of video games and reading, no physical education class at school, and lack of energy and motivation.

(Academy, 2014)

V. Nutrition Intervention

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

PES #1: Excessive Energy Intake Goal: The main goal for Missy is to decrease her caloric intake from 4065 kcal a day to 1700-1800 kcal gradually over time. Intervention: First, I would want to educate Missy and her parents about healthy food choices, proper meal and snack portions, how to grocery shop for nutrient-dense foods, and appropriate methods of cooking food to avoid extra fat. I would provide Missy and her parents with an example meal plan for Missy and point out the changes that I made revolving around less fat, sugar, sodium, and calorie-dense beverages. I would suggest skim milk instead of whole milk, low-fat or fat free options, and sugar-free options. I would suggest cutting back on desserts such

Click 16

as Twinkies as snacks and substituting it for something like frozen bananas or grapes. Missy needs to be consuming more fruits and vegetables so I would include different ways that her parents can fit these into her daily meals. I would have Missy and her parents work together on a food log to keep track of her food and beverage consumption. At first, I would suggest that Missy and her parents focus on maintaining her weight. I would suggest that she decrease her calorie consumption to 2800 calories to start, which should be somewhat “easy” to do, for example, by switching methods of cooking meat (fried to grilled or baked) and switching from skim to whole milk. They should then decrease her caloric intake by 200 kcal every two weeks so that in a little over two months, Missy is at her goal caloric intake of 1700-1800 kcal. By providing nutrient-dense foods for Missy, instead of empty calories, she will become full more quickly. I would also have her parents note her mood when she wants to eat to see if there is a connection between her moods and her hunger. Overall, this transition to healthy eating for Missy will be a family effort and she will need their support and encouragement to make the changes needed.

PES #2: Physical Inactivity Goal: The main goal for Missy here is to increase her movement throughout the day. She currently has little to no exercise and her hobbies are playing video games and reading. Her goal will be to engage in physical activity for 30 minutes 3-5 times a week. Intervention: I would first educate Missy and her parents on the importance of physical activity in a growing child’s life and the many benefits that come from it, including physical, emotional, and mental health. I would work with Missy to see what activities she would be comfortable doing and then I would suggest that the family invest in a membership to their local YMCA-like facility. They can also go to a nearby park if they have one in their community. Since Missy is not getting any activity at her school since they cut physical education, she needs to be active when she is home. I would recommend that Missy and her family exercise together and make it a family event. I would suggest that they exercise at least 3-5 times a week for 30 minutes at a time. This time and number of days can then increase over time gradually as well. In a month, they should attempt to be active at least 5 times a week for 30-45 minutes a day. I would also educate Missy and her parents appropriate pre- and post-workout snacks that will fuel Missy for the activity. Lastly, I would Missy to keep a physical activity log to track her progress and write down what activity she did and how she felt about it.

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

I would tell Mr. and Mrs. Bloyd that I would not recommend using over-the-counter diet aids, such as Alli (orlistat). The drug orlistat comes in two names, Xenical and Alli. Xenical, the prescription, has been available since 1999 and the FDA has approved it for adults and children over the age of 12. This drug contains 120 mg of orlistat. The over-the-counter version of orlistat is called Alli and contains 60 mg orlistat and is only approved for adults. For use in the approved population, orlistat has seen some progress (about 5 to 7 pounds in 1 to 2 years) but nothing drastic. It works by blocking some of the fat that you consume and keeping it from being absorbed. Common side effects could include stomach pain, diarrhea, gas, and leakage. Since the FDA has not approved this drug, in either form (prescription or over-the-counter) for children of Missy’s age, I would strongly dissuade her parents from using these drugs with Missy. The drug

Click 17

would most likely do more harm than good in her case. I would suggest that they stay patient and positive for Missy and encourage her to make healthy changes in her diet and physical activity level to see results.

Prescription medications for the treatment of obesity. (n.d.). Retrieved October 12, 2014, from

http://www.win.niddk.nih.gov/publications/prescription.htm

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

Gastric bypass surgery in the pediatric population is normally done when there are other health problems related to the obese state. Some general guidelines that determine if a child is a candidate for the surgery are 1) a BMI of or above 35 with a serious health condition associated to obesity and 2) a BMI of or above 40 with a less serious health condition associated to obesity. Serious health conditions may include diabetes, pseudotumor (pressure in the skull), severe sleep apnea, or severe inflammation of the liver. Less serious health conditions may include high blood pressure, high cholesterol, mild sleep apnea, or depression. Other factors that should be taken into consideration are if the child was unable to lose weight through diet and exercise for a period of at least 6 months, whether or not the child has finished growing (usually 13 years or older for girls), and whether or not the patient and family is psychologically ready for the lifestyle changes following the surgery. Given these guidelines, I would say that Missy is currently not a candidate for the surgery for several reasons. Her BMI does not fit the guidelines, however, if she were to keep up her current lifestyle it could increase very quickly. Also, she is only 10 years old so the surgery could come with complications over the next couple years as she continues to grow. Lastly, she has not tried a healthier diet plan and exercise for over six months without weight loss yet. Her health concerns of sleep apnea and increased glucose levels associated with her weight are better treated with weight management to start with physical activity and then gradual diet and exercise intervention at her age and current BMI.

Weight-loss surgery and children. (n.d.). Retrieved October 12, 2014, from

http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000356.htm

VI. Nutrition Monitoring and Evaluation

24. When should the next counseling session with Missy be scheduled?

It would be beneficial to follow-up with Missy on a regular basis. Before determining when her next counseling session should be scheduled, her degree of readiness to change should be assessed. If it seems like Missy could use more counseling, then a follow-up should be scheduled sooner rather than later to build readiness through motivational interviewing. This could be in the next few weeks to revisit how Missy is feeling about he goals put in place and her degree of motivation for making healthy changes. Once her and her family are noticeably motivated, frequent visits should be scheduled after that. It would be helpful to see Missy and her family every two weeks for at least four months if she is motivated.

Click 18

Liu, L. (2012, October 1). Managing overweight and obesity. Retrieved October 12, 2014, from

https://www.seattlechildrens.org/healthcare-professionals/resources/consult/october-

2012-managing-overweight-obesity/

25. Should her parents be included? Why or why not?

While there is insufficient evidence comparing child-only counseling to child and parents together, according to the EAL, including the parents in treatment is expected to be more effective considering child-only interventions (ages 6-12) have evidence of being ineffective. Additionally, numerous studies have shown that family counseling as part of a multi-component program has resulted in improvements in adiposity and weight status in the short and long term for this age group. Including the parents would not only get them involved in their child’s health and show support, but it would also educate them as well. If the parents are educated and on the same page with Missy, then they are more likely to know how to help her achieve her goals.

Pediatric weight management: family-based counseling. (2006). Retrieved October 12, 2014,

from https://www.andeal.org/topic.cfm?menu=5296&pcat=4176&cat=5461

Pediatric weight management: family interventions: child only versus parents, children together.

(2006). Retrieved October 12, 2014, from https://www.andeal.org/topic.cfm?

menu=5296&pcat=2935&cat=2897

26. What would you assess during this follow-up counseling session?

During Missy’s follow-up counseling session, I would want to assess how she is managing the recommended changes that were set out for her and her family. First, I would assess how she is handling her new diet changes in reduced total calorie intake, fat, sugar, sodium, empty calories, and calorie-dense beverages. I would look over her food log and discuss her progress and any challenges or concerns for her and her family. Secondly, I would have her labs taken again to check on her lipid profile and blood glucose test results. I would compare the results with the initial visit and see if the values have stabilized and/or reduced/increased toward the middle of the normal range instead of nearing the border. Thirdly, I would assess how progress is going with Missy’s physical activities and check to see if she has started to enjoy any new hobbies that require her to be active. I would go over her physical activity journal with her and her parents and also address any challenges or concerns. Fourth, I would want to assess how Missy is sleeping now. It is my hope that the changes in diet and exercise will help with her sleeping at night and with her energy during the day. I would want to see if they have started to see any changes in her mood and energy levels so far. Lastly, I would encourage Missy and her family and use positive reinforcement to ensure them that they are doing the right thing and are on the right track to a healthier lifestyle by following the goals and recommendations. I would go over

Click 19

what I want them to continue to work on as a family and schedule another follow-up so that there is constant communication to keep Missy and her family motivated. They would also be able to contact me via email for progress on food and fitness logs as well as questions and concerns.

References

Click 20

Academy of Nutrition and Dietetics (2014). Pocket guide for international dietetics & nutrition

terminology (IDNT) reference manual: Standardized language for the nutrition care

process. Chicago, Ill: Academy of Nutrition and Dietetics.

BMI-for-age (5-19 years). (n.d.). Retrieved October 12, 2014, from

http://www.who.int/growthref/who2007_bmi_for_age/en/

Choose a food group. (n.d.). Retrieved October 12, 2014, from

http://www.choosemyplate.gov/food-groups/

Daily food plan. (n.d.). Retrieved October 12, 2014, from

http://www.choosemyplate.gov/myplate/index.aspx

Daniels, S., Arnett, D., Eckel, R., Gidding, S., Hayman, L., Kumanyika, S., ... Williams, C.

(n.d.). Overweight in children and adolescents. Retrieved October 12, 2014, from

http://circ.ahajournals.org/content/111/15/1999.full

Defining childhood obesity. (n.d.). Retrieved October 12, 2014, from

http://www.hsph.harvard.edu/obesity-prevention-source/obesity-definition/defining-

childhood-obesity/

Food log. (n.d.). Retrieved October 12, 2014, from http://www.fitday.com/app/log/foods

Gavin, M. (2012, October 1). Overweight and obesity. Retrieved October 12, 2014, from

http://www.kidshealth.org/parent/general/body/overweight_obesity.html

HbA1c. (n.d.). Retrieved October 12, 2014, from

http://www.ucsfbenioffchildrens.org/tests/003640.htm

Jessup, A., & Harrell, J. (n.d.). The metabolic syndrome: Look for it in children and adolescents

too. Retrieved October 12, 2014, from

http://clinical.diabetesjournals.org/content/23/1/26.full

Click 21

Karnik, S., & Kanekar, A. (2012, January 1). Childhood obesity: A global public health crisis.

Retrieved October 12, 2014, from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278864/

Liu, L. (2012, October 1). Managing overweight and obesity. Retrieved October 12, 2014, from

https://www.seattlechildrens.org/healthcare-professionals/resources/consult/october-

2012-managing-overweight-obesity/

Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition therapy and

pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.

Obesity and sleep. (n.d.). Retrieved October 12, 2014, from http://sleepfoundation.org/sleep-

topics/obesity-and-sleep

Pediatric weight management: family-based counseling. (2006). Retrieved October 12, 2014,

from https://www.andeal.org/topic.cfm?menu=5296&pcat=4176&cat=5461

Pediatric weight management: family interventions: child only versus parents, children together.

(2006). Retrieved October 12, 2014, from https://www.andeal.org/topic.cfm?

menu=5296&pcat=2935&cat=2897

Prescription medications for the treatment of obesity. (n.d.). Retrieved October 12, 2014, from

http://www.win.niddk.nih.gov/publications/prescription.htm

Sleep apnea. (n.d.). Retrieved October 12, 2014, from http://sleepfoundation.org/sleep-disorders-

problems/sleep-apnea

Supertracker. (n.d.). Retrieved October 12, 2014, from

https://www.supertracker.usda.gov/foodtracker.aspx

Weight-loss surgery and children. (n.d.). Retrieved October 12, 2014, from

http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000356.htm

Click 22

Weight management. (n.d.). Retrieved October 12, 2014, from

http://www.stanfordchildrens.org/en/topic/default?id=weight-management-and-

adolescents-90-P01626

What are the health risks of overweight and obesity? (n.d.). Retrieved October 12, 2014, from

http://www.nhlbi.nih.gov/health/health-topics/topics/obe/risks.html

Why parents shouldn't use food as a reward or punishment. (n.d.). Retrieved October 12, 2014,

from http://www.urmc.rochester.edu/encyclopedia/content.aspx?

ContentTypeID=160&ContentID=32

Click 23