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Chelsie Fellman

Weight Management Case Study


KNH 411
October 10, 2015

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); behavioralenvironmental (sedentary lifestyle, socioeconomic status,
modernization, culture, and dietary intake); and global (society,
community, organizational, interpersonal, and individual).
Biological: If there is prevalence of obesity and
chronic diseases related to obesity, then the child is
much more likely to develop obesity related chronic
diseases. According to Nelms (p. 259), genetics play
an immense role in determining whether a child is
more likely to develop something that a close family
member had.
Behavioral-environmental: NHANES data collected
from 2005 until 2008 revealed associations between
obesity and socioeconomic status measured in terms
of educational level or income. The key findings from
the report simply claim that a person with lower
income is more likely to be overweight or obese than
that of a person with higher income (Nelms, p. 259).
In essence, poverty and obesity go hand-in-hand and
are closely related. Based on Missys history, she
leads a pretty sedentary lifestyle, which is a major
contributing factor as to why she is obese for her
age. Children in todays society are more often
exposed to things like television and video games as
opposed to playing games outside and being
physically active; this ties into the sedentary lifestyle
factor and will only cause the problem to augment.
The culture the family practice plays a major role in
what they consume in their diet. Some cultures
believe in eating an all vegan diet for example and
others might eat high amounts of saturated fats and
lard.
The global aspect that contributes to childhood
obesity would be attributed to the fact that children
do not get much say in what they eat at home. The
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caregivers are the ones that provide the meals and


set the bar as to what the child should eat and what
the child can eat (essentially whats available). If the
family is qualified for the SNAP program, it might not
be socially acceptable for them to claim the benefits
of this program. Inevitably, there is a much bigger
picture that contributes to the multifactorial aspects
of childhood obesity.
2. Describe health consequences associated with an overweight
condition. Describe how these health consequences differ for an
overweight versus and obese condition.
There are many health consequences associated with
an overweight condition. When the body has more
adipose tissue to supply energy and oxygen to, it
becomes distressed. Problems such as type two
diabetes, hypertension, osteoporosis and difficulties
breathing are a few of the many problems that could
arise with being overweight. A lot of individuals suffer
from knee and joint pain because the body has to
carry an extra amount of weight around. Being
overweight can also be directly related to breathing
problems and difficulties sleeping, such as sleep
apnea (p. 260).
With an individual who is obese, a lot of these
problems that occur are the same but tend to be
more serious. It is much more difficult for someone
that is obese to go to the gym and work out, for
example. So inevitably, it ends up being more
difficult for the obese individual overall to move
around and use the energy that they are consuming.
The location of the body fat distribution is an
important concept when considering the health
implications of overweight and obesity as well. If the
individual predominantly carries abdominal or central
body fat, they are more likely to suffer from
cardiovascular complications related to the obesity
(p. 257).

3. Missy has been diagnosed with obstructive sleep apnea. Define


sleep apnea. Explain the relationship between sleep apnea and
obesity.
According to MayoClinic, sleep apnea is defined as,
a potentially serious sleep disorder in which the
breathing repeatedly stops and starts. The three
main types of sleep apnea are: obstructive sleep
apnea, when the throat muscles relax; central sleep
apnea, which occurs when your brain doesnt send
proper signals to the muscles that control breathing;
and complex sleep apnea syndrome, which occurs
when someone has both obstructive sleep apnea and
central sleep apnea (MayoClinic, 2015).
According to Nelms, when the body has a lot of
central adipose tissue, the obese individual will
struggle to inhale appropriate amounts of oxygen.
This could range from someone who snores through
the night all the way to someone like Missy- who was
diagnosed with obstructive sleep apnea where
breathing stops at various points during the night (p.
266).

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 Nelms, in the pediatric population, the
goals for weight loss are for the individual to be at or
under the 85th percentile (p. 266). The treatment of
overweight and obesity requires comprehensive
assessment and management. Management includes
applying recommended therapies to both achieve
and maintain weight loss and to prevent or treat
other obesity related disease risk factors (p. 266).
The case in which it would not be appropriate to lose
weight is if the child is aged 0-36 months. This time
period of growth is critical for the child to grow to
their fullest potential (AAP, 2015).

5. What would you recommend as the current focus for nutritional


treatment of Missys obesity?
I believe that the first step the medical team should
take would be to educate Missy and her family on
foods that are good for her to consume and to also
inform her on the benefits of exercise. It is important
for Missy to understand that she is consuming too
many saturated fats (as evidenced by her 24-hour
recall) and so information on what foods to stay away
from would benefit her greatly. The current focus will
essentially be the educational aspect to attempt to
get Missy and her family on track. Following the
education process, we will get Missy on a diet
regimen that allows her to eat delicious and healthy
foods in an attempt to bring her weight down no
more than 1-2 pounds a week.

Nutrition Assessment
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.
According to Nelms, overweight in pediatrics is
defined as, 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).
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. Overweight 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
(Centers for Disease Control and Prevention, 2013).
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According to the World Health Organization,


overweight and obesity definitions are combined and
defined with a broad statement of, ''abnormal or
excessive fat accumulation that presents a risk to
health'' (WHO, 2015).
All the sources provided apart from the World Health
Organization use the BMI percentile in their definition
to describe how it is determined if an adolescent is
overweight. Using the BMI percentile as opposed to
an actual BMI is more useful in determining how
much a child is overweight because this system
takes into account the differences in body fat
distribution among boys and girls at different ages.

7. Evaluate Missys weight using the CDC growth charts provided.


What is Missys BMI percentile? How would her weight status be
classified by each of the standards you identified in question 6?
According to the CDC growth charts provided, Missy
would be considered to be in the 97th percentile for
her BMI. This classifies her to be obese. She is
considered to be obese by all three standards that I
classified in question 6.

Calculation of Nutrient Requirements


8. If possible, RMR should be measured by indirect calorimetry.
Identify two methods for determining Missys energy
requirements other than indirect calorimetry and then use them
to calculate Missys energy requirements.
Using the Mifflin method, 10 x weight (kg) + 6.25 x
height (cm) 5 (age) -161
10 x (52 kg) + 6.25 x (145 cm) 5(10) - 161 = 1,215
kcal

Harris-Benedict- 655 + 9.56 weight(kg) + 1.85


height(cm) - 4.68 (age)
655 + 9.56 (52 kg) + 1.85 (145 cm) 4.68 (10) =
1,374 kcal

Intake Domain
9. Dietary factors associated with increased risk of overweight are
increased dietary fat intake and increased kilocalorie-dense
beverages. Identify foods from Missys diet recall that fit these
criteria. Calculate the percentage of kilocalories from each
macronutrient and the percentage of kilocalories provided by
fluids for Missys 24-hour recall.
Just after quickly assessing Missys 24-hour recall, it
is apparent to me that she is consuming excessive
amounts of fat and excessive amounts of added
sugar in her diet as evidenced by the whole milk,
added cream and sugar to her coffee, mayonnaise,
Frito corn chips, Twinkies, fried chicken, fried okra,
microwave popcorn and the Coca-Cola. As you can
see below, after entering Missys 24-hour recall data
into SuperTracker, it is apparent that she is taking in
too many calories throughout the day. Her total
caloric intake for her 24-hour recall was 4,558 kcals
nearly three times the amount she needs in a day.
% kilocalories Carbohydrates: 35%
% kilocalories Protein: 15%
% Kilocalories Fat: 43%
% kilocalories from beverages: 12%
It is important to note that about 1,000 kcals came
from Missys beverage intake alone.

Missys 24-hour recall information:

Food Groups

Target

Average Eaten

Grains

5 ounce(s)

13 ounce(s)

Whole Grains

3 ounce(s)

1 ounce(s)

Refined Grains

2 ounce(s)

12 ounce(s)

2 cup(s)

1 cup(s)

Dark Green

1 cup(s)/week

0 cup(s)

Red & Orange

4 cup(s)/week

0 cup(s)

Beans & Peas

1 cup(s)/week

0 cup(s)

Vegetables

Starchy

4 cup(s)/week

1 cup(s)

Other

3 cup(s)/week

cup(s)

1 cup(s)

cup(s)

Whole Fruit

No Specific Target

0 cup(s)

Fruit Juice

No Specific Target

cup(s)

3 cup(s)

6 cup(s)

Milk & Yogurt

No Specific Target

3 cup(s)

Cheese

No Specific Target

2 cup(s)

5 ounce(s)

12 ounce(s)

Seafood

8 ounce(s)/week

0 ounce(s)

Meat, Poultry & Eggs

No Specific Target

10 ounce(s)

Nuts, Seeds & Soy

No Specific Target

2 ounce(s)

Oils

5 teaspoon

15 teaspoon

Limits

Allowance

Average Eaten

Total Calories

1600 Calories

4558 Calories

121 Calories

1643 Calories

Solid Fats

1133 Calories

Added Sugars

509 Calories

Fruits

Dairy

Protein Foods

Empty Calories*

10.
Increased fruit and vegetable intake is associated with
decreased risk of overweight. Using Missys usual intake, is
Missys fruit and vegetable intake adequate?
Using Missys usual intake, it is apparent that she is not
consuming adequate amounts of fruits and vegetables.
According to the MyPlate SuperTracker tool, she is under in
both of those categories. The servings of fruits that she did
get were primarily from fruit juices. Her 24-hour recall does
not show any signs that Missy consumes whole fruits and
vegetables, which puts her at an increased risk for
remaining obese and only continuing to gain more weight.

11.
Use MyPlate Plan online tool to generate a personalized
MyPlate for Missy. Using this eating pattern, plan a 1-day menu
for Missy.

See question 9 above for the information provided on


Missys 24-hour recall for her macronutrients
Based on Missys 24-hour recall, we need to get her total
caloric intake down to between 1,400-1,600kcals/day. Here
is a 1-day menu I have created in order to meet Missys
caloric needs:
o Breakfast: 1 slice of whole-wheat toast with 1 tbsp.
peanut butter. cup fresh peaches. One cup of 1%
milk.
o Lunch: Turkey sandwich on whole wheat bread with 1
slice of mozzarella cheese and 2 oz. turkey. 1 bag of
baked lays chips. 1 serving of fresh carrots with 1
tsp. ranch dressing
o Snack: 8 oz low-fat strawberry yogurt. 1 c cauliflower.
o Dinner: 3 oz baked chicken. 1 cup of mixed
vegetables. cup brown rice. 1 c spinach salad
o Dessert: sliced apples cooked in 1 tsp butter and 1
tsp. cinnamon
o Snack: 1 banana with 1 tbsp crunchy peanut butter.
One Cup 1% milk.

12.
Now enter and assess the 1-day menu you planned for
Missy using the Myplate SuperTracker online tool. Does your
menu meet macro- and micronutrient recommendations for
Missy?

Food Groups

Target

Average Eaten

Grains

5 ounce(s)

8 ounce(s)

Whole Grains

3 ounce(s)

3 ounce(s)

Refined Grains

2 ounce(s)

5 ounce(s)

2 cup(s)

3 cup(s)

Dark Green

1 cup(s)/week

0 cup(s)

Red & Orange

4 cup(s)/week

1 cup(s)

Beans & Peas

1 cup(s)/week

0 cup(s)

Starchy

4 cup(s)/week

cup(s)

Vegetables

Other

3 cup(s)/week

1 cup(s)

1 cup(s)

2 cup(s)

Whole Fruit

No Specific Target

2 cup(s)

Fruit Juice

No Specific Target

0 cup(s)

3 cup(s)

3 cup(s)

Milk & Yogurt

No Specific Target

3 cup(s)

Cheese

No Specific Target

cup(s)

5 ounce(s)

7 ounce(s)

Seafood

8 ounce(s)/week

0 ounce(s)

Meat, Poultry & Eggs

No Specific Target

5 ounce(s)

Nuts, Seeds & Soy

No Specific Target

2 ounce(s)

Oils

5 teaspoon

2 teaspoon

Limits

Allowance

Average Eaten

Total Calories

1600 Calories

1738 Calories

121 Calories

180 Calories

Solid Fats

102 Calories

Added Sugars

78 Calories

Fruits

Dairy

Protein Foods

Empty Calories*

According to SuperTracker, this 1-day meal plan does meet


Missys needs. It is within a ballpark of what she needs and
by lowering her total calories consumed daily by about
2,800 kcals, this will ensure Missy will lose weight.

Clinical Domain
13.
Why did Dr. Null order a lipid profile and blood glucose
test?
Dr. Null ordered a lipid profile to evaluate the damage of
Missys lipids such as her cholesterol levels- HDL and LDL
in particular.
The glucose test was ordered because it would not be
surprising if Missys pancreas were struggling to produce
insulin- resulting in type 2 diabetes as a result of her being
obese for her age. Her family history indicates a
prevalence of type 2 diabetes in both her mother and her

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grandmother putting Missy at an even higher risk for


developing type 2 diabetes.

14.
What lipid and glucose levels are considered to be
abnormal for the pediatric population?
The normal blood glucose range for the pediatric
population should be between 70-110 mg/dL. Missys BG
was 108, which isnt quite out of range, but it should be
lower than that. According to the NIH, it is normal for a
fasting pediatric blood glucose level to be anywhere
between 70-85mg/dL, so with this information, Missy has
indications that her pancreas is struggling. She is inevitably
on the brink of type 2 diabetes (NIH, 2013).
According to the American Academy of Pediatrics, Lipid
levels that are considered to be normal for the pediatric
population are 120-199 mg/dL. Missy has total cholesterol
of 190mg/dL, which is in fact on the high side. Having high
cholesterol at the mere age of 10 can potentially be
detrimental to Missys heart health and her overall well
being (AAP, 2015).

15.

Evaluate Missys lab results


Reviewing Missys lab results, she is particularly high in her
total cholesterol level at 190mg/dL when anything above
199mg/dL is considered abnormally high.
Her total LDLs are also elevated but not quite abnormal at
110mg/dL.
Her HDL was lower than usual at 50mg/dL when normal is
anything above 55mg/dL.
Her elevated blood glucose level of 108mg/dL is a risk
factor for type 2 diabetes mellitus. Her hemoglobin A1c
test shows that she has a 5.5 A1c indicating that her
average blood glucose over the past three months has
been 106, which is higher than it should be for the
pediatric population (American diabetes association, 2015).

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Behavioral-Environmental Domain
16.
What behaviors associated with increased risk of
overweight would you look for when assessing Missys and her
familys diets?
I would look for sedentary lifestyle behaviors, high-stress,
lack of sleep, poor diet and overall well being (i.e.socioeconomic status and state of nutrition related
education).

17.
What aspects of Missys lifestyle place her at increased risk
for overweight?
Missy lives a sedentary lifestyle for a child her age.
According to her 24-hour dietary recall, she is uneducated
on what foods she should consume and what foods are
detrimental to her health. She also consumes a very
calorie-dense diet with little to no fruits and vegetables,
which is inevitably going to be damaging to her health. The
fact that she is not very active in general combined with
her diet is directly related to her Missy being obese.

18.
You talk with Missy and her parents. They are all friendly
and cooperative. Missys 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 kindly tell them that it is better for Missy to eat in
between meals; in fact, thats what I would recommend in
her dietary prescription because eating more often keeps
the bodys metabolism running and helps keep the body
full longer (granted that Missy is consuming foods that are
nutrient dense).
As for rewarding Missy with dessert when she exercises, I
would curb them away form this idea because it will only
set Missy up for disaster in the end. I would encourage the
family to help Missy out by exercising with her, and eating
healthier meals and snacks with her to positively reinforce
what she should be doing. If the family participates with

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the child in a weight-loss regimen, the child is 75% more


likely to participate and follow through (NIH, 2015).

19.
Identify one specific physical activity recommendation for
Missy.
One specific physical activity recommendation for Missy
would be to go outside and play more often. In todays
society, unfortunately kids are more exposed to technology
and being indoors, resulting in a lack of creativity and lack
of exercise overall. I would encourage Missy to play outside
more with her neighbors or siblings if she has any. This will
enable her to become more active overall, and she will
have fun being active, too!

Nutrition Diagnosis
20.
Select two high-priority nutrition problems and complete
PES statements for each.
Excessive oral intake (NI 2.2) related to 24-hour recall as
evidenced by total daily caloric intake of 5,558 kilocalories.
Physical inactivity (NB 2.1) related to exercise and nutrition
related knowledge deficit as evidenced by documentation
of obese abdomen.
(IDNT, 2011)

Nutrition Intervention
21.
For each PES statement written, establish an ideal goal
(based on signs and symptoms) and an appropriate intervention
(based on etiology).
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Excessive oral intake (NI 2.2) related to 24-hour recall as


evidenced by total daily caloric intake of 5,558 kilocalories.
o An ideal goal to combat this PES statement above
would be for Missy to lose 1-2 pounds per week until
she is at her IBW of 85 pounds. Something we can do
as an intervention is to educate Missy on highfat/high-carb meals that are poor for her health. We
would do so by having a lesson that would be both
fun and beneficial to Missy so she would be more
likely to take the information she learns, home. It is
important for Missy to lose weight and one of the
interventions we are going to utilize is to have Missy
document all the food she eats into a food diary so
that at the next appointment with the dietitian, we
can discuss what she is improving on and what may
still need further guidance.
Physical inactivity (NB 2.1) related to exercise and nutrition
related knowledge deficit as evidenced by documentation
of obese abdomen.
o Seeing as Missy leads a sedentary lifestyle according
to her history, this alone is vastly contributing to her
being overweight. She needs to be informed on the
benefits of exercise for her body. To combat this
problem, we will educate Missy on exercises that she
can do at home and things that she can do differently
in general- such as walking up the stairs a few more
times a day. Playing outside is a good source of
exercise for children of this age and so we will
encourage Missy to play outside more as well. Missy
will keep documentation on what she did that was
good exercise for her every day until she meets with
the dietitian again.

22.
Mr. and Mrs. Bloyd ask about using over-the-counter diet
aids such as Alli (Orlistat). What would you tell them?
I would encourage Mr. and Mrs. Bloyd to avoid diet aids
such as Alli. Diet aids usually have more disadvantages
than advantages and the weight that typically is lost with a

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diet aid is water weight. A person should not lose more


than 2 pounds in a week for this can be harmful in many
ways to the body as well. The plan that we have for Missy
thats in place right now should work provided that both
Missy and her family are on board with the intervention.

23.
Mr. and Mrs. Bloyd ask about the gastric bypass surgery
for Missy. What are the recommendations for the pediatric
population for gastric bypass surgery?
According to the American Society for Metabolic and
Bariatric Surgery, selection criteria for adolescents for
bariatric surgery are as follows:
The child has to have a BMI greater than or equal to
35kg/m2 with major co-morbidities (i.e., type 2 diabetes
mellitus, moderate to severe sleep apnea, pseudo tumor
cerebri, or severe NASH)
Or a BMI of 40 kg/m2 with other co-morbidities (e.g.,
hypertension, insulin resistance, glucose intolerance,
substantially impaired quality of life or activities of daily
living, dyslipidemia, sleep apnea with apnea-hypopnea
Missy does not have any of these problems and so as for
right now, it would be completely unnecessary for her to
have bariatric surgery.
(ASMBS, 2015)

Nutrition Monitoring and Evaluation


24. When should the next counseling session with Missy be
scheduled?
The next counseling session should be scheduled in one
month from the initial counseling session. This gives Missy
enough time to get a start on her weight-loss adventure.
She will be provided all the materials that she needs to
document her journey such as her daily food log and
exercise habits.

25.

Should her parents be included? Why or why not?


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26.

Missy is only 10 years of age so it is imperative that her


parents are included in not only the counseling sessions,
but also this entire process. Missys parents play a key role
in her success for they are who she looks up to and who
will be supporting her all throughout this journey.

What would you assess during this follow-up session.


First, I would assess how the changes worked for Missy
overall in the first month. I would ask her questions such
as, how did documenting your food go? And, Did you get
to try any new exercises or foods that you enjoyed?
Secondly, I would assess her new anthropometric data to
see if she has lost any weight and made any progress.
Even if she has only lost two pounds, we would know we
were headed in the right direction.
Thirdly, we would take Missys blood glucose and make
sure that her BG remains in the normal range of 70mg/dL
110mg/dL.
Lastly, I would assess that both Missy and her parents are
aware of the end goals for Missy and that they are on track
to success overall. We would meet again 1-2 months later
to assess further progress being made by Missy.

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References
American Academy of Pediatrics: Overweight and Obesity.
http://www.aap.org/obesity/
American Diabetes Association. (n.d.). Retrieved October 7, 2015.
Centers for Disease Control and Prevention (CDC). Defining Childhood
Obesity. (2015, June 19). Retrieved October 11, 2015.
International dietetics and nutrition terminology (IDNT) reference
manual:
Standardized language for the nutrition care process. (3rd ed.).
(2011).
Chicago, IL: American Dietetic Association.
Mayo Clinic: Childhood Obesity (2015, May 10). Retrieved from
http://www.mayoclinic.org/diseases-conditions/childhoodobesity/basics/definition/con-20027428
National Institutes of Health (NIH). (2013, August 12). Retrieved
October 5, 2015
from http://www.cdc.gov/obesity/childhood/defining.html
Nelms, M., & Roth, S. (2004). Medical nutrition therapy: A case study
approach (2nd
ed.). Belmont, CA: Wadsworth/Thomson Learning.
Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.).
Belmont, CA:
Wadsworth, Cengage Learning.
Pediatric Best Practice Guidelines - American Society for Metabolic and
Bariatric Surgery. (2015, December 5). Retrieved October 6, 2015.

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World Health Organization (WHO) What is overweight and obesity?


(2015, July 2).
Retrieved October 4, 2015, from
http://www.who.int/dietphysicalactivity/childhood_what/en/

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