Pediatric Weight Management
Kelly Davis
KNH 411
Case Study #1
October 8, 2013
1. Current research indicates that the cause of childhood obesity is multifactorial.
Briefly outline the roles of genetics, environment, and nutritional intake in
development of obesity in children.
In the past 30 years, childhood obesity has more than doubled in children and
tripled in adolescents. There are many factors or causes of childhood obesity but
some of the most common are genetics, environment, and nutritional intake. In
some cases, children gain genes from their parents that help them easily gain
weight but in other cases some inherit medical disorders caused by their
overweight parents. The most common diseases children are at risk for include,
high cholesterol, high blood pressure, early heart disease, diabetes, bone
problems, and skin conditions such as heat rash, fungal infections, and acne.
Although weight problems may run in the family, not all children with a family
history of obesity will become overweight. Children who have parents, brothers,
or sisters who are overweight have an increased risk of becoming overweight
which can be linked to factors such as environment and family behaviors.
Family, friends, school, and community influence a child’s lifestyle habits
regarding diet and activity. At home, the parent to child interaction is crucial
because parents can influence their children’s food choices. Today, there is a
significant increase in the number of working parents, which means there is less
time to prepare meals and more fast food is being consumed. Kids spend most of
their days at school and around their friends where they may find more peer
pressure and fast, easy ways to get food, for example vending machines. The
community also plays a role in childhood obesity depending on the community’s
lack of accessibility and affordability of healthy food. The last factor, nutritional
intake, is a main cause of childhood obesity. Children are now consuming an
increased amount of calories and fat and a decreased amount of fruit and
vegetables. This is due to restaurants and food companies overemphasizing
buffets, processed foods, and overeating.
Childhood Obesity. (2013). Retrieved from
http://www.childrensdefense.org/policy-priorities/childrens-health/childnutrition/childhood-obesity.html
2. Describe health consequences of overweight and obesity for children
There are many health consequences for children who are overweight or obese.
Overweight or obese children can have high blood pressure and high cholesterol,
which are risk factors for cardiovascular disease. They have an increased risk of
impaired glucose intolerance, insulin resistance, and type 2 diabetes. Children
may develop breathing problems such as sleep apnea and asthma, joint
problems, and musculoskeletal discomfort. Obese children and adolescents also
have a greater risk of social and psychological problems, which include poor selfesteem and discrimination. In conclusion, overweight and obese children are
more likely to become overweight or obese adults due to the health
consequences they accumulated as a child.
Basics About Childhood Obesity. (2012, April 27). Retrieved from
http://www.cdc.gov/obesity/childhood/basics.html
3. Jamey has been diagnosed with obstructive sleep apnea. Define sleep apnea.
Sleep apnea is a common disorder in which you have one or more pauses in
breathing or shallow breaths while sleeping. Breathing pauses can last from a
few seconds to minutes. This condition usually disrupts your sleep, moving you
out of deep sleep into light sleep, which then leaves you tired in the next day.
The most common type of sleep apnea is obstructive sleep apnea. In this
condition, the airway collapses or becomes blocked during sleep causing shallow
breathing or breathing pauses. When you try to breathe, any air that squeezes
by the blockage causes loud snoring. Obstructive sleep apnea is most common in
overweight individuals.
What is Sleep Apnea?. (2012, July 20). Retrieved from
http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/
4. Explain the relationship between sleep apnea and obesity.
The relationship between sleep apnea and obesity is that sleep apnea can cause
obesity and obesity can cause sleep apnea; it’s a cycle! Those who sleep less
tend to eat more and there seems to be a relationship between hunger and
satiety hormones and sleep deprivation yet the relationship is unclear.
Individuals with sleep apnea often have elevated blood pressure, fasting glucose,
and high cholesterol, all of which are made worse with sleep deprivation.
Obesity, which can lead to sleep apnea, causes unbalance of hormones that
control eating habits, leading to more weight gain, worsened blood pressure,
glucose intolerance, and worsened apnea making the cycle continue.
Obesity and Sleep. (2013). Retrieved from
http://www.sleepfoundation.org/article/sleep-topics/obesity-and-sleep
5. What are the goals for weight loss in the pediatric population?
There are many goals for weight loss in the pediatric population. According to
the Academy of Nutrition and Dietetics the main goal is to avoid restrictive diets
and excessive exercise regimens. Another goal is to ensure that children grow
and develop normally in order to reach a health weight. Children need a
positive, reassuring atmosphere for healthy eating and activity habits. Parents
need to set healthy limits on screen time (1-2 hours per day) which include
television and video games. Parents should also help their children develop a
positive body image and involve the whole family in healthy activities.
Healthy Weights for Healthy Kids. (2012, November). Retrieved from
http://www.eatright.org/Public/content.aspx?id=10929
6. Under what circumstances might weight loss in overweight children not be
appropriate?
Unlike adults, children need calories for growth and development, in addition to
the calories that their body requires for daily metabolism and physical activity.
Children who eat too little may not have enough calories to grow in height.
Children’s calories should not be cut too much, that is why weight loss
recommendations for children are modest and restrictive diets and excessive
exercise is very inappropriate.
Healthy Weights for Healthy Kids. (2012, November). Retrieved from
http://www.eatright.org/Public/content.aspx?id=10929
7. What would you recommend as the current focus for nutritional treatment of
Jamey’s obesity?
For Jamey’s obesity, the current focus should be on physical activity, healthy
eating, and portion control. I would recommend that she reduce the amount of
sedentary activities she is involved in and increase in active play. This could
include playing outside, going on a walk with the family, or even playing a wii
instead of watching TV. I would also recommend slowly introducing more
healthy options into Jamey’s diet. The amount of saturated fat and sodium in her
diet needs to gradually decrease and the amount of fruit and vegetables needs to
increase. Jamey also needs to focus on portion control. Two breakfast burritos
for breakfast and two bologna sandwiches for lunch can be a lot for a 10 year
old. Reducing this to one burrito and one sandwich could be a step in the right
direction for Jamey.
8. Evaluate Jamey’s weight using the CDC growth charts provided: What is Jamey’s
BMI percentile? How is her weight status classified? Use the growth chart to
determine Jamey’s optimal weight for height and age.
According to the CDC growth charts provided, Jamey’s BMI value of 24.9 puts her
in the 97th percentile for BMI. If a patient has a BMI that is equal or greater than
the 95th percentile, they are considered obese. Using the growth chart, Jamey’s
optimal weight for her height and age was determined to be 92 pounds and her
body weight should be at a BMI at the 85th percentile or below.
9. Identify two methods for determining Jamey’s energy requirements other than
indirect calorimetry, and then use them to calculate Jamey’s energy
requirements.
Mifflin St. Joer
(10 x weight kg) + (6.25 x height cm) – (5 x age) – 161
(10 x 52.2 kg) + (6.25 x 145 cm) – (5 x 10 yr old) -161
= 1,217 kcals
Harris Benedict
655 + (9.56 x wt (kg)) + (1.85 x ht (cm)) – (4.68 x age (yrs))
655 + (9.56 x (52.2 kg)) + (1.85 x (145cm)) – (4.68 x (10))
=1,376 kcals
Both equations are used to determine the amount of calories Jamey requires
each day in order to account for her resting metabolic rate.
10. Dietary factors associated with increase risk of overweight are increased dietary
fat intake and increased calorie-dense beverages. Identify foods from Jamey’s
diet recall that fit these criteria.
After reviewing Jamey’s 24-hour diet recall, there were many foods that could
have contributed to the increase in her caloric intake and overall obesity. From
her diet recall she consumed a large amount of high fat foods, which included,
whole milk, cream, bologna, cheese, mayonnaise, Fritos, Twinkies, fried chicken,
and fried okra. She also consumed a large amount of calorie dense beverages,
which included, whole milk, apple juice, Coca-Cola, and sweet tea.
11. Calculate the percent of kcal from each macronutrient and the percent of kcal
provided by fluids for Jamey’s 24-hour recall.
Jamey consumed about 4,488 kcals over a 24-hour period. The amount of kcals
from fat is 40.3%, 43.3% kcals comes from carbohydrates, and 17% of kcals
comes from protein. Jamey also consumed 18% of her calories from beverages.
Total kcals = 4,488
Fat= 200.8 grams x 9g = 1807.2/4,488 = 40.3%
Carbs= 486.0 grams x 4g= 1,944/4,488 kcals= 43.3%
Protien = 188.6 grams x 4 g = 754.4 / 4,488 kcals= 17%
Beverage= 810 kcals/4,488 kcals= 18%
12. Increased fruit and vegetable intake is associated with decreased risk of
overweight. What foods in Jamey’s diet fall into these categories?
Jamey is not consuming enough fruits or vegetables. She should be consuming
about 3-4 servings of fruit and vegetables each day. According to her 24-hr
recall the only fruit she ate was jelly on a sandwich and apple juice, which are
not fresh sources. She also needs to increase her vegetable intake. The only
vegetables she ate were either fried or made with whole milk and butter.
Overall, Jamey needs to increase the amount of fresh fruits and vegetables she is
consuming.
13. Use the ChooseMyPlate online tool to generate a customized daily food plan.
Using this eating pattern, plan a 1-day menu for Jamey.
Breakfast:
1 c. oatmeal
½ c. blueberries
8 oz. skim milk
Lunch:
Peanut Butter Sandwich- 2 slices whole grain bread, 2T peanut butter
½ c. raw carrots
½ c. celery sticks
½ c. apple slices
Snack:
2 c. popcorn
½ c. strawberries
Dinner:
3 oz. Grilled Chicken
Small Green Salad; carrots, tomatoes, lite Italian dressing
½ c. wild rice
8 oz. skim milk
Snack:
1 c. Frozen Yogurt
14. Now enter and assess the 1-day menu you planned for Jamey using the MyPlate
SuperTracker online tool. Does your menu meet macro- and micronutrient
recommendations for Jamey?
Total kcals= 1,325
Carbohydrates= 186 g x 4g = 744/1,325 kcal= 56%
Protein = 67g x 4g = 268/1,325 kcal = 20%
Fat = 34g x 9g = 306/1,325 kcal = 23%
The meal I created met all the macro and micronutrient recommendations for
Jamey. All of the appropriate amounts of dairy, meat, fruits, vegetables, and
whole grains were met. The only thing that was low was the amount of fat that
Jamey was given. The appropriate amount of fat should range between 25-35%
of the patients total calories. In Jamey’s case, her meal was lower in fat with
about 23% of her calories coming from fat. Also, the total calories for the meal
should have been around 1,600 calories for a girl her age and the amount she
was given was about 1,325.
15. Why did Dr. Lambert order a lipid profile and blood glucose tests? What lipid
and glucose levels are considered altered (outside of normal limits) for pediatric
population? Evaluate Jamey’s lab results.
Dr. Lambert ordered a lipid profile and blood glucose tests in order to assess
Jamey’s current health state. She already has been diagnosed with sleep apnea,
complains of joint pain, and her mother and grandmother have type 2 diabetes.
Since she is very overweight, it is important to check labs and make sure Jamey
doesn’t have any other greater health risks. Also, dyslipidemia and insulin
insensitivity are two conditions that are often associated with obesity. So having
the doctor order these tests addresses the issue that Jamey may experience
other health complications due to her weight. Abnormal glucose levels for the
pediatric population 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. Most of Jamey’s lab results are within the normal ranges expect for a few
concerning areas. Her glucose levels are slightly high, being 112 mg/dL. Her
HDL levels are extremely low at 34 mg/dL and her LDL/HDL ratio is slightly
over the recommended range at 3.23.
Lab Results
Glucose (mg/dL)
HDL (mg/dL)
LDL/HDL ratio
Ref. Range
70-110
>55
<3.22
9/22
112
34
3.23
16. What behaviors associated with increased risk of overweight would you look for
when assessing Jamey’s and her family’s diets? What aspects of Jamey’s lifestyle
place her at increased risk for overweight?
When assessing Jamey and her family’s diets I would look at the amount of total
fat and saturated fat they are consuming. I would assess their portion sizes and
how often they are eating throughout the day. I would also assess how often
they go out to eat, consume fast food, and how strict Jamey’s parents are on her
consumption of food. With an increased risk of being overweight, family history
should also be looked at to check for serious disease such as diabetes,
cardiovascular disease, and obesity. The aspects of Jamey’s lifestyle that place
her at an increased risk for overweight is her large consumption of high fat
foods, her very sedentary lifestyle, and the large quantity of food she consumes
at meals which leads to an excessive energy intake.
17. You talk with Jamey and her parents, who are friendly and cooperative. Jamey’s
mother asks if it would help for them to not let Jamey snack between meals and
to reward her with dessert when she exercises. What would you tell them?
I would advise Jamey’s parents to let her eat healthy snacks between meals, such
as fruits and vegetables. This will help keep her metabolism active and running
smoothly. I would advise them not to reward her with desserts after exercising.
This will give Jamey mixed messages about rewards and will increase her fat and
calories intake. If the reward system works for this family, reward Jamey with a
fun activity instead of food.
18. Identify one specific physical activity recommendation for Jamey.
I recommend that Jamey try to get involved in an extracurricular activity outside
of school. She should sign up for an activity that meets 3x a week for 30-60
minutes such as soccer, gymnastics, or swimming. Getting involved and meeting
other children could help to increase Jamey’s confidence and boost her selfesteem.
19. Select two nutrition problems and complete PES statements for each.


Excessive calorie intake related to large consumption of high fat foods as
evidence by diet history and BMI of 24.9.
Inadequate fruit and vegetable intake related to overweight and obesity as
evidence by 24-hr diet recall.
20. For each PES statement written, establish an ideal goal (based on signs and
symptoms) and an appropriate intervention (based on etiology).

Goal- Portion Control of foods consumed and reduce BMI to a healthy range.
Intervention- Patient will decrease amount of calories consumed to 25-35%
of fat coming from total calories.

Goal- Increase the amount of fruits and vegetables consumed
Intervention- Recommend patient consume 3-5 servings of fruits and
vegetables each day, which can include, but not limited to: apple, banana,
grapes, strawberries, carrots, celery, peas, and corn.
21. Mr. and Mrs. Whitmer ask about using over-the counter diet aids, specifically Alli
(orlistat). What would you tell them?
I would not recommend this over the counter diet aid for their daughter Jamey.
Drugs like Alli are not recommended for children under the age of 12 and from
12-18 patients should consult a doctor before use. I would encourage Jamey to
try to lose weight by exercising regularly and decreasing her energy intake to a
healthy range for her age. If she still doesn’t see the results she is looking for by
age 12, then the family should consult the family doctor for further instructions.
Weight loss drugs: Alli and xenical. (2009, August). Retrieved from
http://www.consumerreports.org/cro/2012/04/weight-loss-drugs-alli-andxenical-orlistat/index.htm
22. Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey. Using the
EAL, what are the recommendations regarding bypass surgery for the pediatric
population?
Bypass surgery is not recommended for the pediatric population. Most children
do not stop fully developing and growing until he or she reaches early adulthood.
During this time of growth there are many important nutrients the body needs
and are mainly found in the stomach. If a child were to have this surgery they
would have trouble retaining the proper amount of calcium, vitamin d, iron, as
well as bone loss and anemia.
23. What is the optimal length of weight management therapy for Jamey?
I would recommend that Jamey return for therapy in 1-3 weeks. Due to the
severity of her obesity and sleep apnea it is important to see her sooner rather
than later to make sure she is on track. One to three weeks will also allow
enough time for changes to be made and will allow changes in weight loss and
overall health to be more easily noticed.
24. Should her parents be included? Why or why not.
I believe that Jamey’s parents should be included in the weight management
therapy sessions. Age 10 is still very young to sit with an adult and talk about
serious health issues such as obesity. Children could become very shy and
hesitant because they are in an uncomfortable situation. I also think it is
important that her parents be included because helping Jamey become healthier
will be a family affair. The program would focus on teaching the entire family
how to eat better, cook healthier, and work together to motivate each other to
maintain a healthier lifestyle through healthy eating and physical activity.
25. What would you assess during this follow up counseling session?
During the follow up counseling sessions I would assess the diet changes that Jamey
has made. I would assess the amount of physical activity she participates in daily and
I would measure her weight and BMI-for- age again. Finally, I would assess her labs
again specifically her lipid and blood glucose levels to see if any improvements have
been made.