Caitlin Mazurek
KNH 411
10/6/11
Weight Management Case Study
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); behavioralenvironmental (sedentary lifestyle, socioeconomic status, modernization, culture, and
dietary intake); and global (society, community, organizational, interpersonal, and
individual).
The presence of childhood obesity has nearly tripled within the past thirty years. It is seen
that obese adolescents are at an increased risk of becoming obese adults and experiencing
the health risks associated with obesity. The prevalence of obesity increases with age until
the age of 64. It has been proven that higher socioeconomic status is associated with a
lower prevalence of obesity. On the school side, physical activity has lessened due to the cut
of physical education programs in schools due to budget cuts. Time is also a struggle as
there is less time to work out. There is also an increase in electronic media and there are
fewer sidewalks for safe walking in neighborhoods. The workplace is more automated and
chores are being filled with labor-saving machinery and automobile travel is more common
than biking or walking. In a more global aspect, Hispanics and African-Americans are
individuals that have the prevalence of obesity partially due to their culture of eating big
meals. The growth of the fast food industry has grown significantly and food is now eaten
more often out of the home and food and beverages are more readily available. Overall,
there is also an increased number of snack and convenience foods. Marketing for foods has
also increased particularly to children and now more than ever, more money is available to
spend on food.
2. Describe health consequences associated with an overweight condition. Describe how
these health consequences differ for overweight versus an obese condition.
Being overweigh for children and adolescents means having a BMI-for-age-and-sex at or
above the 85th percentile, but less than the 95th percentile using the CDC growth charts.
Obesity for children and adolescents is defined as a BMI-for-age at or above the 95th
percentile using the CDC growth charts. Obesity actually comes from the Latin word
obesus, meaning one who has become plump through eating. It is the excess of body fat or
adipose tissue and is a proportion of body weight that is adipose tissue that is greater than
some standard. Health consequences related to being overweight include increased risk of
type 2 diabetes, hypertension, dyslipidemia, coronary heart disease, and metabolic
syndrome. When a person is obese, the chance at getting one or more of these health
consequences is heightened. The more a person weighs is directly related to their chances
of these health problems.
3. Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea. Explain the
relationship between sleep apnea and obesity.
Obstructive sleep apnea, or OSA is repeated interruption of sleep by ventilator disruptions
that result from mechanical collapse of the airway. Being overweight is one of the risk
factors. Being obese can cause the adipose tissue to build up in the neck area and when
sleeping, it can cause interruptions.
4. What are the goals for weight loss in the pediatric population? Under what
circumstances might weight loss in overweight children not be appropriate?
In the pediatric population, the goals of weight loss are for the individual to be at or under
the 85th percentile. It is not appropriate for children who are overweight to lose weight if
they are still very young such as infants. Infants through toddlers should be able to grow
and continue to grow to their fullest potential. Weight should not start to be worried about
until around the age of 8 unless there is an extreme. Kids need to eat and grow so that their
brains can grow and they can learn.
5. What would you recommend as the current focus for nutritional treatment of Missy’s
obesity?
I would recommend for the current focus for nutritional treatment of Missy’s obesity to be
cutting out or down her caloric intake in beverages. In beverages alone, Missy was
consuming nearly 1000 calories. This is about 60% of what her recommended caloric
intake should be.
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.
Overweight- an excess of body weight in relationship to height; for children and
adolescents, overweight can be defined as a BMI-for-age-and-sex at or above the 85th
percentile using the CDC growth charts (Nelms, 239).
Overweight- BMI ranges for children and teens are defined so that they take into account
normal differences in body fat between boys and girls and differences in body fat at various
stages, it is defined as a BMI at or above the 85th percentile and lower than the 95th
percentile for children of the same age and sex (http://www.cdc.gov/obesity/childhood/).
Overweight- weighing too much or more than is considered normal, proper, etc.
(http://www.dictionary.com).
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?
Missy is considered to be in the 97th BMI percentile. This would classify Missy as not only
overweight, but obese. She is way above what she should be.
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.
Mifflin-St. Jeor- 10 x weight (kg) + 6.25 x height (cm) – 5 (age) -161
10 x (53 kg) + 6.25 x (145 cm) – 5(10) - 161 = 1225 kcal
Harris-Benedict- 655 + 9.56 weight(kg) + 1.85 height(cm) - 4.68 (age)
655 + 9.56 (53 kg) + 1.85 (145 cm) – 4.68 (10) = 1383.2 kcal
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.
Foods that are high in fat from Missy’s diet include the whole milk, mayonnaise, frito chips,
twinkies, bologna, cream in her coffee, fried chicken, fried okra, and mashed potatoes made
with whole milk and butter. The high calorie dense beverages include her whole milk,
sweet tea, and coca-cola. Carbohydrates provided 34% of her diet, protein consisted of
17% of her diet, and fat made up 49% of her kilocalories. Fluids made up of 19% of the
total calories consumed for Missy. Almost 1,000 calories were from her beverages.
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?
Based on Missy’s 24-hour recall, her usual intake of fruits and vegetables is not adequate.
She has two servings of vegetables for the entire day, where it included a starchy vegetable
and a fried vegetable, which barely counts since it was mashed potatoes filled with fat and
okra fried in oil. Five fruits and vegetables are recommended daily and I would say that
Missy barely got one. Based off of MyPlate, she had ½ cup equivalent when the equivalent
recommended is 1.5 cup equivalent.
11. Use the MyPlate Plan online tool to generate a personalized MyPlate for Missy.
According to MyPlate, Missy is above the recommendation for every category except for
fruit and vegetables. She is at 197% for milk, 342% for meat and beans, 252% for grains,
and then only 72% for vegetables and 33% for fruits.
12. Using this eating pattern, plan a 1-day menu for Missy.
According to Missy’s eating pattern and the recommendations from MyPlate, it is
important to decrease intake from over 5,000 calories to around 1,750 calories a day.
Breakfast: 1 c Cheerios with ½ c 1% milk 2 pieces of whole wheat toast with 3 sprays of I
Can’t Believe It’s Not Butter spray
Snack: 1 apple sliced with 2 T of peanut butter
Lunch: 1 turkey wrap in a whole-wheat tortilla, spinach leaves, tomato slices, and mustard
with a 1 oz bag of Baked Lays potato chips, 8 oz 1% milk, 2 Hershey Kisses
Dinner: Shrimp stir fry with 1 c brown rice, ½ c carrots, ½ c broccoli, 2 oz of shrimp, and 8
oz of orange juice
Snack: 1 medium banana and one box of raisins
13. Now enter and assess the 1-day menu you planned for Missy using the MyPlate tracker
online tool. Does your menu meet macro- and micronutrient recommendations for
Missy?
This 1-day menu meets all the recommendations that MyPlate has set. It meets the
caloric intake exactly and as well as all the micronutrient recommendations such as
calcium, sodium, vitamins A, B, C, E, potassium, and fiber. The fiber aspect I tried to make
really important so that Missy will be satisfied between meals and snacks. The
macronutrients all matched within 10 grams except for the carbohydrates. My menu was
far above the recommendation by about twice as much. A way to cut this amount down
would be to eventually cut out the toast in the morning breakfast.
14. Why did Dr. Null order a lipid profile and a blood glucose test?
Since Missy’s mom had possible gestational diabetes and currently has type 2 diabetes,
it would not be uncommon for Missy to develop type 2 diabetes or have type 1 diabetes.
The blood glucose test will determine where Missy is on this spectrum. The lipid profile is
to see where Missy’s cholesterol levels are and how much damage she has done to her
heart and other organs and how much her veins and arteries are filled with cholesterol.
15. What lipid and glucose levels are considered to be abnormal for the pediatric
population?
The normal glucose levels should be between 70-110 mg/dL where Missy’s was 108
mg/dL. Lipid levels that are considered to be normal are 120-199 mg/dL where Missy’s
was 190 mg/dL. Anything too far outside of these levels would be considered abnormal.
16. Evaluate Missy’s lab results.
In her lab results, it was seen that her cholesterol was borderline high at 190 where 199
is considered the upper number of normal. Her HDL was not high enough at only a 50
where over 55 is recommended. Her A1C came back as high too where 3.9-5.2 is
considered normal and Missy’s was at 5.5. A1C is the new indicator for type 2 diabetes. It is
possible that since her A1C is so high, that Missy could be diabetic. Her glucose was
borderline high at 108 where 110 is considered to be normal.
17. What behaviors associated with increased risk of overweight would you look for when
assessing Missy’s and her family’s diets?
I would ask where they live and how her parents get to work and how Missy gets to
school. If she lives close enough to walk to school or if she has to take the bus. The overall
behavior that I would be looking into would be the amount of physical activity that can be
attained. I would also like to find out how often they eat out of the house. This would allow
me to see what their daily life patterns are and find out how to help them make healthier
choices when they are out of the house.
18. What aspects of Missy’s lifestyle place her at increased risk for overweight?
Missy has little to no physical activity and leads a sedentary lifestyle. Missy is also a child of
a parent with type 2 diabetes.
19. 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 inform them that she is allowed to snack in between meals, as long as the
snacks are nutritious. There is a difference between having a snack of a full peanut butter
and jelly sandwich and an apple with peanut butter or baby carrots with a fat-free ranch. If
Missy does exercise, it should be something that she wants to do. The reward should be to
get her life back and not to get to eat more. The dessert will almost cancel her working out
all together.
20. Identify one specific physical activity recommendation for Missy.
Missy should have a goal of walking around the block once every day after dinner. After
two weeks, she should try to make the walk longer and walk one extra street. Two weeks
after that, she should walk around the block twice each day. In the future, her goal should
be to do it in a light jog or speed walk her walk around the block each night after dinner.
21. Select two high-priority nutrition problems and complete PES statements for each.
- Patient’s caloric intake is too high related to poor dietary intake as evidenced by the
24-hour recall and high BMI.
- Patient’s caloric intake from beverages is too high related to poor dietary intake and
lack of nutritional education as evidenced by the 24-hour recall.
22. For each PES statement written, establish an ideal goal (based on signs and symptoms)
and an appropriate intervention (based on etiology).
- I plan on giving nutrition education to Missy and her parents on what a day of food
should look like and explain the importance of fiber, whole grains, and fruits and
vegetables. I would also link the importance of a healthy diet to show them that you
can lose weight by eating healthier and through losing weight, then Missy will
hopefully lose her sleep apnea. This would be the main goal for Missy to lose weight
and to not have sleep apnea anymore.
- I plan on giving nutrition education that explains the intake of all the unneeded
calories Missy is taking in through beverages. I would show them that I calculated
almost 1000 calories from Missy’s 24-hour recall were from beverages alone.
23. Mr. and Mrs. Bloyd ask about using over-the-counter diet aids, specifically Alli (orlistat).
What would you tell them?
Over-the-counter diet aids are something that I would not recommend, personally. I feel
that by changing your diet should be enough of a start for you right now. There are so many
risks to taking a diet aid and I feel that there are more risks than benefits. The weight that
is lost using a diet aid is mostly water weight, and therefore will not be sustained after you
stop using the diet aid. The key to great weight loss is a healthy diet that is well balanced
and includes all of the major nutrients.
24. 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 is not recommended for the pediatric population, because it is so
difficult when the children are still growing. Since their bodies are not fully grown, it is
hard to do major surgery and mess with something as major as the digestion system. I
would tell the parents that I think it is really important to lose weight with healthy living
before any major surgery is considered. It has been seen that if pediatrics do get the
surgery, they are more likely to go back to their poor eating habits and gain the weight back
anyways later in life. It is important to give thorough nutrition education so that Missy can
learn what is good to eat and what is not as well as how to live a healthy lifestyle.
25. When should the next counseling session with Missy be scheduled?
I feel that the next counseling session should be in 4-6 weeks. I would like to see how
after the sleep apnea is treated with either a mask or something like that, and starting to do
some physical activity has helped Missy’s weight.
26. Should her parents be included? Why or why not?
Missy’s parents should definitely be included in this meeting, so that they can hear how
things are going and they can learn how their part of buying and preparing the food is
working or not. Missy is only ten years old and is still dependent on what her parents
prepare for her. She can make her own choices when she’s at school, but most likely two of
her meals a day are eaten at home and prepared or bought by her parents.
27. What would you assess during this follow-up counseling session?
During the follow-up counseling session, I would be sure to look at Missy’s weight and
hopefully weight loss. I would ask if they have been keeping a food diary or not and see
how things are going. I would ask Missy if she is going on her daily walk around the block
and see how she likes this little physical activity. I would like to be able to give them a 5day menu and work together with them on what is feasible and see how we can change
things for the better. I would make sure to inform them that I am available for more help if
they need it and am willing to work with them on helping Missy get healthy so that her
sleep apnea will hopefully go away.