Meghan Ames

Mrs. Matuszak

KNH 406

February 23, 2010

Weight Management Case Study #3

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).

Biological factors include genetic influences such as appetite, taste preferences, energy

intake, resting energy expenditure, the thermic effect of food, nonexercise activity

thermogenesis, and the body’s efficiency in storing energy. Behavioral-environmental

influences include social influences, such as poverty, food availability, cultural food

practices, family values, and availability of resources. Global influences include location

of grocery stores, legal restrictions, food resources, extracurricular activities, methods of

transportation, fast-food restaurants, and many more factors.

2) Describe health consequences association with an overweight condition. Describe how

these health consequences differ for an overweight versus an obese condition.

Type II diabetes is three times as prevalent among obese people resulting from elevated

plasma free fatty acids, insulin resistance, reduced glycogen stores, and increased hepatic

glucose production. These complications are significantly less common in overweight

individuals than obese people. Obese individuals are also more likely to have high blood

pressure and dyslipidemia. Certain cancers, breathing difficulties, arthritis, and

reproductive complications are also associated with obesity. Modest weight loss in an

overweight or obese individual and result in reduced risk of certain diseases and

improved health.

3) Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea. Explain the

relationship between sleep apnea and obesity.

Obstructive sleep apnea is a condition resulting in brief cessation of breathing during

sleep due to a relaxation of the throat muscles. It is seen more commonly in overweight

or obese individuals because extra soft tissue can thicken the wall of the windpipe,

restricting the opening.

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?

According to the Journal of the American Dietetic Association, there are four main goals

for treatment of pediatric obesity: 1) reduce energy intake; 2) increase energy

expenditure; 3) actively engage primary caretakers; and 4) facilitate a supportive

environment (Kirk, et. al.). Additionally, the child’s age and severity of obesity should be

considered when prescribing treatment. Obesity in older children can be treated as adults,

whereas treatment in younger children may take a more conservative approach, and allow

for long-term weight loss over time, resulting from simple lifestyle changes. Aggressive

weight loss interventions may be inappropriate for younger children (< 8 years) who are

only moderately obese (BMI < 30), as the natural aging process may address weight

concerns.

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

obesity?

Because Missy is still fairly young, I would focus on intervention efforts that impact

Missy’s health habits, such as diet and exercise. Rather than setting a daily calorie goal

to achieve a certain weight, I would challenge Missy to incorporate certain dietary goals,

such as fruits and vegetables, into her daily routine in hopes that a healthier diet would

lead to weight loss as she continues to grow.

Nutrition Assessment

A) Evaluation of Weight/Body Composition

6) Overweight or obesity in adults is defined by BMI. Children and adolescent 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 Maternal and Child Health Bureau, Health Resources and Services Administration,

the Department of Health and Human Services committee of pediatric obesity experts

recommends the following criteria for diagnosing obesity in children:

BMI ≥ 85th percentile with complications of obesity

BMI ≥ 95th percentile with or without complications

where complications of obesity include hypertension, dyslipidemias, orthopedic

disorders, sleep disorders, gall bladder disease, and insulin resistance (Barlow, et.

al.)

The American Academy of Pediatrics and the American Dietetic Association both cited

pediatric obesity criteria as those with a BMI greater than the 95th percentile (where

children with a BMI greater than the 85% percentile are considered overweight).

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?

59” (1.50 m) and 115 lbs (52.3 kg)

BMI = 23.2, 95th percentile for age

Missy’s BMI of 23.2 puts her just above the 90th percentile for her age. According to both

the American Academy of Pediatrics and the American Dietetic Association, Missy is

considered obese. She could also be classified as obese according to the definition used

by the Maternal and Child Health Bureau because her BMI is above the 95th percentile

and she suffers from a sleep disorder, which is a complication of obesity.

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.

Alternative methods for finding RMR include direct calorimetry, doubly labeled water,

and energy estimation equations. Two equations that could be used to calculate Missy’s

energy requirements are the Harris Benedict and the IOM for overweight females aged 3

through 18.

Harris Benedict: REE = 655.1 + 9.6 (52.3) + 1.9 (1.50) – 4.7 (10) = 1,113 kcal

TEE = 1.2 (REE) = 1,336 kcal

IOM: TEE = 389 – 41.2 (10) + 1.00 (15.0 * 52.3 + 701.6 * 1.50) = 1,814 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.

Food Item Exchange Carbohydrate Protein Fat

2 brkfst burritos 4 cho

2 med. fat meat

2 fat

60

14

10

10

8 oz. whole milk 1 whole milk 12 8 8

4 oz. apple juice 1 fruit 15

6 oz. coffee n/a

¼ c. cream 2 fat 10

2 t. sugar 2 other carb 30

4 slices bread 4 starch 60 12 2

4 oz. bologna 4 high-fat meat 28 32

2 oz. cheese 2 high-fat meat 14 16

1 T. mayo 3 fat 15

1 oz. corn chips 1 starch

1 fat

15 3

5

2 twinkies 4 carb

4 fat

60

20

8 oz. whole milk 1 whole milk 12 8 8

2 slices bread 2 starch 30 6

2 T. peanut butter 4 fat 20

2 T. jelly 2 carb 30

12 oz. whole milk 1.5 whole milk 18 12 12

3 pieces (6 oz) fried chicken 6 med-fat meat 42 30

1 c. mashed potatoes 2 starch 30 6

1 c. fried okra 1 starch

1 fat

15 3

5

20 oz. sweet tea 4 carb 60

3 c. microwave popcorn 1 starch

1 fat

15 3

5

12 oz. coca-cola 2 carb 30

Total Grams 492 159 208

Total Calories 4476 1968 636 1872

Macronutrient Distribution 44% 14% 42%

Foods contributing to increased fat include fried chicken, whole milk (instead of 1%),

twinkies, bologna, breakfast burritos. High calorie beverages include coca-cola, sweet

tea, and coffee with cream and sugar.

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 diet contains no raw fruits or vegetables. The only fruits are in juice or jelly

form and the only vegetable is fried.

11) Use the MyPyramid Plan online tool to generate a personalized MyPyramid for Missy.

Using this eating pattern, plan a 1-day menu for Missy.

Breakfast: 1 piece white bread with jelly, honey nut cheerios with 1% milk, OJ

Snack: celery and peanut butter

Lunch: ham sandwich with mayo, carrots with low-fat dressing, 1% milk, chocolate chip

cookie

Snack: yogurt with granola

Dinner: chicken breast, broccoli, corn, 1% milk, strawberries

Daily goals: 1600 kcal, 5 oz. grains, 2 cups vegetables, 1.5 cups fruit, 3 cups milk, 5 oz.

meat/beans

12) Now enter and assess the 1-day menu you planned for Missy using the MyPyramid

Tracker online tool. Does your menu meet macro- and micronutrient recommendations

for Missy?

The macronutrient ranges were a bit off (56% carb, 22% protein, 25% fat) resulting in a

relatively low-fat diet (this is interesting considering that the Menu Planner was alerting

me to an excessive fat and oil intake). All of the micronutrient needs were met, with the

exception of fiber which was only 18 g. (RDA is 26 g.).

D) Clinical Domain

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

Dyslipidemia and insulin insensitivity are two conditions that are often associated with

obesity. Dr. Null ordered these tests to address the possibility that Missy may be

experiencing other complications related to her weight.

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

Abnormal glucose levels are < 70 mg/dL and > 110 mg/dL. Abnormal lipid levels include

a cholesterol < 120 or > 199 mg/dL, HDL < 55 mg/dL, and LDL > 130 mg/dL.

15) Evaluate Missy’s lab results.

Missy’s lipid levels are all within the normal limits except for her HDL, which is low (50

mg/dL). Her other lipid levels, however, are approaching the high end of the normal

range (T-chol is 190 mg/dL and LDL is 110 mg/dL). Glucose is also on the high side of

the normal limits at 108 mg/dL.

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 diet?

Frequent consumption of fast- or prepared-foods, sugary beverages, few fruits and

vegetables, large portion sizes, and sedentary lifestyle.

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

Diet consisting of few fruits and vegetables, high-fat snacks, and sugary beverages; little

physical activity.

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?

Focus on a healthy diet, which does not mean skipping snacks, necessarily, but rather

including healthy snacks, like celery and peanut butter. Try to take focus off of food by

not forbidding foods as punishment nor awarding foods as positive reinforcement.

19) Identify one specific physical activity recommendation for Missy.

To incorporate physical activity into Missy’s day-to-day life, she might benefit from

joining a sports team or even having a Wii Fit so that physical activity does not seem like

a chore, but rather is something fun that she looks forward to.

Nutrition Diagnosis

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

Excessive energy (NI-1.5) and fat intake (NI-51.2) RT dietary selections of high-fat meat

and sugary snack products AEB dietary recall (intake exceeding 4,000 kcal and fat

distribution of 42%).

Food and nutrition-related knowledge deficit (NB-1.1) RT no prior instruction, lack of

familial support and disinterest in learning AEB dietary selection of high-fat mean and

sugary snack products.

Nutrition Intervention

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

and an appropriate intervention (based on etiology).

Reduce energy intake to 1800 kcal per day by selecting low-fat meats and low-calorie

snacks.

Plan meals to meet the MyPyramid goals of 5 oz. grains, 2 cups vegetables, 1.5 cups

fruit, 3 cups milk, 5 oz. meat/beans after receiving family and individual instruction on

use of the program.

22) Mr. and Mrs. Bloyd ask about using over-the-counter diet aids, specifically Alli (orlistat).

What would you tell them?

Because of Missy’s young age, drug intervention is not yet necessary, because it is likely

that with changes in her lifestyle and normal growth patterns of a 10 year-old, she will

achieve a healthy weight as she grows.

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 on children Missy’s age is unlikely to be approved by a surgeon.

Recommendations of Inge, et. al. are cited in Pediatrics, suggesting that, among other

requirements, patients achieve skeletal maturity prior to surgery, which occurs around

age 13 for girls (Bradley). In addition, a meta-analysis of various pediatric gastric bypass

surgeries published in Annals of Surgery did cite surgeries on children as young as 9

years-old, a majority of which exhibited 4 or more cardiovascular risk factors, such as TG

> 100 mg/dL, HDL-C < 90th percentile, T-Chol > 200 mg/dL, systolic BP > 90

th

percentile, and strong immediate family history of cardiovascular disease (Treadwell, et.

al.). Missy does not meet either of the criteria recommended for gastric bypass surgery.

References

American Academy of Pediatrics. About childhood obesity. Retrieved February 21, 2010, from,

http://www.aap.org/obesity/about.html

American Dietetic Association. (2010). Pediatric weight management guideline overview.

Retrieved February 21, 2010, from,

http://www.adaevidencelibrary.com/topic.cfm?cat=2722

Barlow, S. E., & Dietz, W. H. (1998, September). Obesity evaluation and treatment: expert

committee recommendations. Journal of the American Academy of Pediatrics. 102(3),

e29. Retrieved from, http://pediatrics.aappublications.org/cgi/content/full/102/3/e29

Kirk, S., Scott, B. J., & Daniels, S.R. (2005, May). Pediatric obesity epidemic: treatment options.

Journal of the American Dietetic Association. 105, S44-51. Retrieved from,

http://www.ncbi.nlm.nih.gov/pubmed/15867895

National Heart Lung and Blood Institute. Sleep Apnea. Retrieved February 21, 2010, from

http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_WhatIs.html

Rodgers, B. M. (2004, July). Bariatric surgery for adolescents: a view from the American

Pediatric Surgical Association. Journal of the American Academy of Pediatrics. 114(1).

255-56. Retrieved from, http://pediatrics.aappublications.org/cgi/content/full/114/1/255