Nutrition 415 Case Study Questions

Oct. 28, 2009

Stephanie Hunley
Kayla Kmet
Lora Lee Aaron
Rebecca Willis

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 pathology);
behavioral-environmental (sedentary lifestyle, socioeconomic status,
modernization, culture, and dietary intake): and global (society, community,
organizational, interpersonal, and individual).
a. Genetics: a child's genes can be mutated and cause obesity or a child can have a
genetic predisposition to become obese although it probably plays a much smaller role
than environmental factors.
b. Behavioral/ environmental: Children participate in many environments. Typically, the
most influential is the home. Their parents' socioeconomic status dictates the food
available and, if both parents work, how much time can be dedicated to preparing food.
As our world continues to quicken its pace, drive throughs and frozen entrées look
increasingly appealing despite their energy and salt density. TV watching is detrimental
on three counts. First, it is a sedentary activity that can sustain engagement for hours,
taking time away from active play for children to learn, rev up their metabolism, use
calories, build muscle, coordination, strong bones, and cardiovascular fitness. Second, it
encourages snacking, and snacking, and snaking. Whether it is healthy food or
unhealthy, too much is consumed. Thirdly, commercials advertise unhealthy foods to
children as part of our culture's marketing strategy and it works. Children learn to desire
unhealthy foods they see on TV. One reason many children are inside in the first place
is the reality or the perception that it is unsafe for them to be outside. Especially for
children who's parents work full time, going outside is not an option. Even sadder still,
in children's schools, where they it is safe for them to go outside, many gym programs
are being shut down or punishment for misbehavior is tame taken away from time
outside. Also in schools, although children have some less healthy options, the menu's
in schools represent one third of children's nutritional needs. In addition, there are
policies being put into place to limit or forbid the promotion of "junk food" for parties or
for sail.
c. Global/ personal- Globally, larger portion sizes are the trend. Consumers pay more
and get more, but they also eat more just because it is on their plates. We are now at a
place at least in America that we actually believe that the typical portion sizes we
receive at restaurants are what we should actually be eating, which is also know as
portion distortion. Another global trend in the US has been the urban sprawl. Because
our homes, businesses, and grocery stores are too far apart to walk, we drive
everywhere, even if it is across the parking lot, because it is esyer. We, as a society,
have learned to expect easy access to whatever we need. Further, there is all most no
where we can not drive to. A trend in families is the dinner table's status as the sacred
gathering place of the family. With out that status, less care may be taken regarding the
quality of the food; plus, families loose the interactions needed to teach children how to
make good food choices and why.

2. Describe health consequences associated with an overweight condition.

Describe how these health consequences differ for an overweight versus an
obese condition.
For every five point increase in BMI a person enters a higher bracket of disease risk.
The diseases and conditions do not necessarily increase in number, but the likelihood of
developing the co morbidities, diabetes, gall bladder disease, hypertension,
dyslipidaemia (too much fat in the blood), and sleep apnea, increase. Other health
related consequences that become more severe or more likely as one progresses from
overweight to obese include coronary heart disease, osteoarthritis (deterioration of
cartilage in knees), hyperuricaemia (too much uric acid in the blood) which may result in
gout (swelling in feet from deposited uric acid), cancer, reproductive hormone
abnormalities, polycystic ovarian syndrome, impaired fertility, low back pain, increased
anaesthetic risk (loss of sensation or consciousness), and fetal defects from maternal
obesity.

3. Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea,
Explain the relationship between sleep apnea and obesity.
Periods during sleep when individuals stop breathing. The correlation between obesity
and disordered sleep exists but it is difficult to pin down exactly why. It may be due to an
alteration in the function of the airways. Researchers have found, in some obese
patients, abnormalities in the soft tissue of their upper air way. Sleep apnea is also
positively correlated to hypertension, a co morbidity of obesity. Weight loss appears to
be effective in treating sleep apnea.

II. Understanding the Nutrition Therapy

4. What are the goals for pediatric weight loss in the pediatric population? Under
what circumstances might weight loss in overweight children not be appropriate?
Reducing sedentary activities like TV viewing and increasing physical activity. Focus of
weight maintenance, not loss because children can grow into their weight, and to reduce
their overall calorie intake below quantities for a normal weight child may result in
impaired growth and development. Especially if the child was ill or had undergone
surgery, weight loss should not be recommended for him/her. The goals should include
the family and progress gradually. For Missy and her family specifically, the family as a
whole can pursue a more active lifestyle by taking a walk, going to a park, or even
playing the wii instead of watching television. The other component is diet. They need
to monitor Missy's intake. Especially if she could keep a food diary herself, she would
become more conscious of her eating and less likely to eat out of boredom if she has to
write it down. Secondly, the food diary would reinforce the idea of portion sizes. Thirdly,
from the food diary, her parents may be able to determine her eating patterns, her
triggers to eat, etc., to provide information for further intervention. Children do tend to
be picky eaters, but there will be no hope of them eating healthy if they are not provided
a variety of healthy choices. In summery, the goals for pediatric weight loss include
weight maintenance so children can grow into the weight, understanding of appropriate
portion sizes, and making nutritionally good food choices when given options.

5. What would you recommend as the current focus for nutritional treatment of
Missy’s obesity?
We would recommend that the Bloyd family pursue a reduction in sedentary activities
and increase in active play. This may look like taking a walk after dinner, going the park
on the weekends, or even playing a wii instead of watching the TV. Also, we would
recommend a focus on portion control, and making healthy choices at home and at
restaurants. This requires a healthy attitude toward food. Food is for the nourishment of
our bodies primarily. Food should not be viewed as comfort, an activity to use time, or a
reward; nor should it be withheld as a punishment. That being said, an overhaul in their
diet may be too violent to be accepted, so they may rather try introducing more healthy
foods gradually and intentionally.

III. Nutrition Assessment

A. 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. u;se three different professional resources and compare/contrast their
definitions for overweight conditions among the pediatric population.
According to Thomas N. Robins and William H. Dietz childhood obesity cannot simply
be defined using a high BMI. Instead they suggest that using the triceps skin fold
thickness and BMI percentiles in combination be used for children of the same age and
sex with a percentile from 85-95 indicating childhood obesity. Similar to Robinson and
Dietz, Nancy F. Krebs has also stated her opinion on childhood obesity indicators in her
article “Normal Childhood Nutrition and Its Disorders” . She also believes that BMI
percentiles from 85-95 in children of the same age and sex to be the key identifier for
obesity, although she does not use skin fold thickness as an indicator. Lastly, Anthony F.
Jerant in the article “Clinical Prevention” also uses BMI plotting charts for age, weight,
and sex to assess occurrence of obesity. He also uses the percentiles between the
range of 85-95 as indicating overweight and obesity. While each uses his or her own
method to determine obesity, we see a common theme of using growth chart percentiles
to determine overweight and obesity. Using research like this, the CDC has issued an
official definition for childhood overweight and obesity. For a child to be overweight he or
she must have a BMI at or above the 85th percentile and lower than the 95th percentile in
the CDC growth charts. Likewise, obesity is defined as a child having a BMI at or above
the 95th percentile in the CDC growth charts for children of the same age and sex.

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.
a) Missy’s height of 4 ft. 9 in. places her in the 77th percentile for her age. Combining
her height and weight ones finds her BMI to be 24.95. While for adults this would not be
considered a poor BMI to have, for Missy’s age her BMI is quite high and places her in
the 98th percentile using the CDC growth charts of children of the same age and sex.. A
BMI in the 98th percentile indicates that Missy is obese according to the definition of
childhood obesity established by the CDC.
b) Because we lack triceps skin fold thickness percentiles, Robinson and Diets may not
yet classify her as obese. However, given her BMI growth chart percentile of 98% both
Krebs and Jerant would agree that Missy should be considered an obese child.

B. Calculation of Energy Requirements

8. If possible, RMR should be measured by indirect calorimetry. Identify two

methods for determining Missy’s energy requirements other that indirect
calorimetry and then use them to calculate Missy’s energy requirements.
One method to calculate energy requirements would be to take one’s BMR and add the
correct amount kcals to balance energy expenditure. The best way to calculate a child’s
EER is to use this equation that was developed specifically for children.
EER for Girls 9 Through 18 Years
EER = TEE + energy deposition
EER = 135.3 − (30.8 × age [y]) + PA × (10.0 × weight [kg] + 934 × height [m]) + 25 kcal
Where PA is the physical activity coefficient:
PA = 1.00 if PAL is estimated to be ≥ 1.0 < 1.4 (sedentary)
PA = 1.16 if PAL is estimated to be ≥ 1.4 < 1.6 (low active)
PA = 1.31 if PAL is estimated to be ≥ 1.6 < 1.9 (active)
PA = 1.56 if PAL is estimated to be ≥ 1.9 < 2.5 (very active)
Missy: Age 10 yrs PA 1.0 Weight kg=52.3 Height m= 1.45
EER= 135.3- (30.8 x10) + 1.0 x (10.0 x 52.3kg + 934x 1.45m) + 25 kcal
EER= 135.3- 308 + 1.0 x 1877.3 + 25kcal
EER= 1729.6 kcal

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.
a)Missy’s increased dietary fat intake and increased kilocalorie dense beverages comes
from the foods and beverages she consumes on a regular basis. From her 24hr diet
recall we see that some of the high fat foods she is consuming are twinkies, peanut
butter, fried okra and chicken, breakfast burritos, bologna sandwiches, fritos and
mayonnaise. We also can identify her kilocalorie dense beverages such as sweet tea,
coca cola, whole milk and coffee with cream and sugar.
b) Using the Mypyramid’s website Menu Planner tool one can see the distribution of
Missy’s calorie intake from her food and beverages.
24hr Recall
Total calories= 4435 kcals
k/cal dense beverages= 402 kcals
-makes up 9.06 percent of total calories
High fat foods= 2697 kcals
-makes up 60.81 percent of total calories

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?
Missy’s fruit and vegetable intake is not adequate. Her only vegetable intake in her 24hr
recall comes from mashed potatoes and fried okra and there was no fruit in her recall,
which can lead one to assume that on a regular basis Missy is not consuming nearly
enough fruits and vegetables.

*11 and 12 are forms from MyPyramid and are attached.

D. Clinical Domain
 13. Why did Mr.Null order a lipid profile and a blood glucose test?
A lipid profile is a group of tests that help determine the risk of heart disease. It
measures cholesterol, triglycerides, and HDL/LDL levels. Because the patient has a
family history of diabetes, high blood pressure, and poor nutritional intake it should be
ordered. A blood glucose test should be ordered because of family history, eating
habits, fatigue. It can help to determine hyper/hypoglycemia and diabetes.

14. What lipid and glucose levels are considered to be abnormal for the pediatric
population?
Blood glucose test
60-100 mg/dL- normal
100-126 mg/dL- pre-diabetes, impaired fasting glucose
126+ mg/dL- diagnosis of diabetes

LDL Cholesterol
Optimal: Less than 110 mg/dL
Borderline high: 110-129 mg/dL
High: Greater than 130 mg/dL

Total Cholesterol
Desirable: Less than 170 mg/dL (5.18 mmol/L)
Borderline high: 170-199 mg/dL (5.18 to 6.18 mmol/L)
High: 200 mg/dL (6.22 mmol/L) or higher

HDL Cholesterol
Low level, increased risk: Less than 35 mg/dL
Average level, average risk: 35-45 mg/dL
High level, less than average risk: 45 +mg/dL

Fasting Triglycerides
Desirable: Less than 125 mg/dL
High: Greater than 125 mg/dL

Evaluate Missy’s lab results.

There is a low ammonia level in Missy’s blood. Ammonia in the body forms when
protein is broken down by bacteria in the intestines. The liver usually converts ammonia
into urea which is excreted. The low ammonia usually coexists with excessive
sleepiness; high ammonia could indicate the childhood disorder of Reye’s Syndrome.
She has high levels of hemoglobin A1c. The HbA1C test is currently one of the best
ways to check diabetes is under control. By measuring the HbA1C levels it can tell you
how high your blood glucose has been on average for the last 8-12 weeks.
E. Behavioral-Environmental Domain

16. What behaviors associated with increased risk of overweight would you look
for when assessing Missy’s and her family’s diets?
frequency/type of meals, physical activities,

17. What aspects of Missy’s lifestyle place her at increased risk for overweight?
High caloric intake, low energy expenditure, unbalanced diet, high fat/ sugar intake, low
fruits and vegetable intake, family history, living situation

18.You talk with Missy and her parents. They are all friendly and cooperative.
Missy’s mother asks if it would help not to let Missy snack between meals and to
reward her with desserts when she exercises. What would you tell them?
Snacking is perfectly fine with the correct nutritional compliments; then i would suggest
some healthy alternatives to popcorn and soda. Rewarding a child with dessert is
counter productive.

19. Identify one specific physical activity recommendation for Missy.

One physical activity recommendation would be to incorporate Wii video games into her
video game routine.

IV. Nutrition Diagnosis

20. Select two high priority nutrition problems and complete PES statements for
each.
a) Excessive fat and sugar intake related to undesirable food choices as evidenced by
24 hour recall.
b) Excessive energy intake related to sedentary lifestyle as evidenced by Nutrition
history.

V. Nutrition Intervention

21. For each PES statement written, establish an ideal goal (based on signs and
symptoms) and an appropriate intervention (based on etilogy).
a) Goal is to decrease Missy’s intake of fat and sugar. Intervention is to change her
dietary behavior by replacing the high fat and sugar foods with lower energy dense
foods such as fruits and vegetables.
b) Goal is for Missy to balance her caloric intake with her output. Intervention is
forMissy to get more physical activity and decrease her total caloric intake.

22. Mr. and Mrs. Bloyd ask abut using over-the-counter diet aids, specifically Alli
(orlistat). What should you tell them?
Alli is for adults 18 and over. Missy should not use Alli or other over-the-counter diet
aids. Missy is still growing and, while her total fat intake should be decreased, fats are
an essential part of her diet. She should reduce her caloric intake and increase her
physical activity if weight loss is recommended.

23. Mr. and Mrs. Bloyd ask about gastric bypass surgery for Missy. What are the
recommendations regarding plastic surgery for the pediatric population?
Gastric Bypass should not be done on children. Missy is still growing and it is important
for her to be able to absorb her required nutrients. Gastric Bypass is not usually done
on people below the age of 18 and a person typically must have a BMI of 40 to qualify
for gastric bypass. Missy’s BMI is 24.94.

VI. Nutritional Monitoring and Evaluation

24. When should the next counseling session with Missy be scheduled?
Counseling sessions with Missy should be scheduled as soon as possible. She needs
to get the appropriate treatment for her sleep apnea and then start Nutrition counseling
immediately.

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

Missy’s parents should definitely be included in her counseling sessions because they
are the ones preparing all of her meals. It is unlikely that any of Missy’s dietary
behaviors will change if her parents are not included.

26. What should you assess during this follow-up counseling session?
In follow up visit, we would assess the short term goals that were originally set for
Missy. These would be the first steps to meeting her long term goals. We would
assess any changes in physical activity and dietary behavior.