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Emily Sinn
ND 568
Grand View Hospital

Case Questions for Medical Nutrition Therapy: A Case Study Approach 4th Ed.

Title: Case 1 – Pediatric Weight Management

Instructions: Answer the questions below. You may print your answers and include them to your ND 568
Binder.

Questions:

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.
a. Genetics- Certain inherited genes from a child’s parents are able to make them gain weight more
easily. An example is a condition called Prader-Willi Syndrome, a disease that begins at birth,
people with this condition constantly feel hungry and become obese. In addition, they have poor
muscle tone, reduced mental ability and underdeveloped sex organs. A missing gene on
chromosome 15 causes Prader-Willi Syndrome and there is no know association with family
history.
b. Environment- A child’s environment includes their time spent at home, at school or out in the
community. At home, if the parents are overweight with poor diet and exercise habits, it is likely
the child will adopt the same habits. Screen time has become a huge problem in the 21st century
and often replaces physical activity time. Screen time is commonly associated with high-calorie
“junk” foods that are also a contributing factor to obesity in all ages. In addition, a families’
geographic location or low income may prevent them from having access of affording nutritious
foods. Lastly, certain communities may not have a strong support system or strong school system
to encourage healthy living or be able to provide well-balanced meals.
c. Nutritional intake- The World Health Organization (WHO) conducted a study titled, ‘Food Types
in the Diet and the Nutrient Intake of Obese and Non-Obese Children’. The purpose of this study
was to compare the nutrient intake of obese children with the intake of non−obese children. A
total of 95 obese and 592 non−obese children aged between 6 and 10 years participated in the
study. The results showed the following information: energy intake of the obese children was
significantly higher than that of the non−obese children, the obese children consumed excessive
fat and sugar, but less fruit and vegetables as compared to the non−obese children.
d. Garipağaoğlu, M., Sahip, Y., Budak, N., Akdikmen, Ö, Altan, T., & Baban, M. (2008, September).
Food Types in the Diet and the Nutrient Intake of Obese and Non−Obese Children. Retrieved
January 19, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3005637/
e. Kaneshiro, N. K. (2016, August 31). Causes and risks for obesity in children. Retrieved January
19, 2018, from https://medlineplus.gov/ency/patientinstructions/000383.htm
f. Obesity: Environmental strategies for preventing childhood obesity. (2004, January 9). Retrieved
January 19, 2018, from http://www.bmsg.org/resources/publications/obesity-environmental-
strategies-for-preventing-childhood-obesity
2. Describe health consequences of overweight and obesity for children.
a. Health consequences commonly associated with overweight and obese children include: asthma,
diabetes, gallstones, heart disease, high blood pressure, liver complications, menstrual problems
and trouble sleeping. In addition, metabolic syndrome occurs between 25-40% of children who
are overweight. Metabolic syndrome includes: abnormal lipids, high blood pressure, insulin
resistance and obesity.

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b. Health Risks of Overweight Children. (n.d.). Retrieved January 19, 2018, from
https://www.ucsfbenioffchildrens.org/education/health_risks_for_overweight_children/
3. Jamey has been diagnosed with obstructive sleep apnea. Define sleep apnea.
a. Obstructive sleep apnea is when the upper airway becomes blocked repeatedly during sleep,
reducing or completely stopping airflow. However, if the brain does not send the signals needed to
breathe, the condition may be called central sleep apnea.
b. Sleep Apnea. (n.d.). Retrieved January 19, 2018, from https://www.nhlbi.nih.gov/health-
topics/sleep-apnea
4. Explain the relationship between sleep apnea and obesity.
a. Being overweight is a high risk factor for the development of obstructive sleep apnea. For
example, carrying excess weight can contribute to breathing problems or if an individual as a
breathing disorder left untreated they could find themselves gaining weight if their condition is left
untreated. Similarly in children, excess weight they gain so young greatly increases their risk for
developing lifelong obstructive sleep apnea (OSA). With weight management, OSA can be cured
while children are still young.
b. Your weight matters: obesity and sleep apnea. (2017, August 24). Retrieved January 19, 2018,
from https://www.sleepapnea.org/weight-matters-obesity-and-sleep-apnea/
5. What are the goals for weight loss in the pediatric population?
a. Weight loss goals in the pediatric population focuses on changing diet habits and increase physical
activity, especially important to have the parents aware and involved. Weight maintenance is
important as children continue to grow and the focus of weight loss begins after a child is done
growing. General guidelines for children over the age of 7 include but are not limited to: slow
changes in eating and exercise, limit fat intake, eat a variety of foods low in calories, decrease
consumption of high fat foods, eat more fruits and vegetables, changes to skim milk and low-fat
fairy products etc.
b. Weight Management. (n.d.). Retrieved January 19, 2018, from
http://www.stanfordchildrens.org/en/topic/default?id=weight-management-and-adolescents-90-
P01626&sid=
6. Under what circumstances might weight loss in overweight children not be appropriate?
a. In general, weight loss is not recommended for children who are still growing even if they are
categorized as overweight or obese. Two primary goals for those overweight or obese children are
for them to maintain their current body weight and as they grow or their height increases they will
transition into a healthy weight and BMI. As a child stops growing, if they are still overweight
then a slow weight loss ~1 lb. a week may be appropriate in addition to making lifestyle changes.
b. Payne, D. J. (2017, November 12). Childhood Obesity | Risks and Statistics. Retrieved January 21,
2018, from https://patient.info/health/obesity-overweight/childhood-obesity
7. What would you recommend as the current focus for nutritional treatment of Jamey’s obesity?
a. I would recommend the current focus for nutritional treatment for Jamey to be to incorporate
minor physical activity into her lifestyle and improve her diet as well. According to the Academy
of Nutrition and Dietetics, the following are easy ways parents can take to help their children
develop positive lifestyle habits: actively playing together, make meals together, eat breakfast
(beyond just cereal), don’t forbid certain foods or give food as a reward, provide a rainbow of
fruits and vegetables, limit sweetened beverages and remove electronic devices or video games
from their rooms. If Jamey’s parents are able to incorporate at least 2 of these strategies into their
home, Jamey’s health could begin to improve.
b. Wolfram, T. (2017, October 19). Help Your Kids Maintain a Healthy Lifestyle. Retrieved January
21, 2018, from http://www.eatright.org/resource/health/weight-loss/your-health-and-your-
weight/helping-kids-maintain-a-healthy-body-weight-a-cheat-sheet-for-success

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8. Evaluate Jamey’s weight using the CDC growth charts provided (p. 8): 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.
a. Jamey’s is 10 years old, 57” and 115 pounds. According to the CDC growth charts Jamey’s BMI
(24.9) percentile is 97% classifying her obese.
b. Jamey’s optimal weight for her height and age would be ~80 lbs. or 36.4 kg.
c. Healthy Weight. (2015, May 15). Retrieved January 21, 2018, from
https://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html
9. Identify two methods for determining Jamey’s energy requirements other than indirect calorimetry, and
then use them to calculate Jamey’s energy requirements.
a. Energy requirements can be identified by either calculating
b. Jamey’s energy requirements are:
i. Example 1: EER for Females 9-18 years
EER= 135.3 - 30.8 x age + PA x (10.0 x weight (kg) + 934 x height (m)) + 25
Weight= 115 lbs./2.2 lbs.= 52.3 kg
Height= 57” x 2.54 in.= 144.8 cm/100cm= 1.45 m
PA= 1.16 for low active
EER= 135.3 – 30.8 x 10 years + 1.16 x (10 x 52.3 kg + 934 x 1.45 m) + 25= 2,030 kcal
a. EER= 2,000-2,100 kcals
ii. Example 2: TEE for Overweight Females Aged 3-18 years
TEE= 389 – 41.2 x age + PA x 15.0 x weight + 701.6 x height o Weight=
115 lbs./2.2lbs. = 52.3 kg
Height= 57” x 2.54 in.= 144.8 cm/100cm= 1.45 m
PA= 1.18 for low active
TEE= 389- 41.2 x 10 years + 1.18 x (15 x 52.3 kg + 701.6 x 1.45m)= 2,103 kcal
TEE= 2,100- 2,200 kcals
c. Position of the American Dietetic Association: Nutrition Guidance for Healthy Children Ages 2 to
11 Years. (2008). Journal of the American Dietetic Association, 108(6), 1038-1047. Doi:
10.1016/j.jada.2008.04.005
10. Dietary factors associated with increased risk of overweight are increased dietary fat intake and increased
calorie-dense beverages. Identify foods from Jamey’s diet recall that fit these criteria.
a. Foods from Jamey’s diet recall that represent high levels of dietary fat intake and calorie-dense
beverages include: breakfast burritos, whole milk, cheese and bologna, mayonnaise, Twinkies,
peanut butter, fried chicken and microwave popcorn. These foods are acceptable when consumed
in moderation however I am not confident Jamey or her parents have a handle on that concept.
11. Calculate the percent of kcal from each macronutrient and the percent of kcal provided by fluids for
Jamey’s 24-hour recall.
a. CHO (45-65%) = 945 - 1,365 kcals from CHO/day
b. Protein (5-20%) = 105 – 420 kcals from protein/day
c. Fat (25-35%) = 525 – 735 kcals from fat/day
d. Fluid (1 mL/kcal) = ~2,100 mL/day

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e. Position of the American Dietetic Association: Nutrition Guidance for Healthy Children Ages 2 to
11 Years. (2008). Journal of the American Dietetic Association, 108(6), 1038-1047. Doi:
10.1016/j.jada.2008.04.005
12. Increased fruit and vegetable intake is associated with decreased risk of overweight. What foods in Jamey’s
diet fall into these categories?
a. Foods in Jamey’s diet that fall into the fruit and vegetable category include: apple juice, grape jelly
and fried okra. Very minimal fruit and vegetable intake from her 24-hour recall and as a growing
child it is essential for her to consume adequate amounts.
13. Use the ChooseMyPlate online tool (available from www.choosemyplate.gov; click on “Daily Food Plans”
under “Super Tracker and Other Tools”) to generate a customized daily food plan. Using this eating pattern,
plan a 1-day menu for Jamey.
a. *See MyPlate Checklist uploaded below to see the general recommendations for Jamey.
b. 1 Day Menu Sample:

Breakfast: Lunch: Dinner: Snacks:


Vegetable omelet with a Peanut butter sandwich Chicken stir-fry: Milk and cereal:
side of yogurt and fresh with a small side of trail
fruit with a glass of milk: mix along with applesauce  1 c. white rice  1 c. whole milk
and a glass of juice:  1 oz. grilled  2 oz. cereal
 1 c. whole milk
 2 slices of chicken
 1 c. fruit multigrain bread  1 c. cooked
 ½ c. fat-free  2 T. creamy vegetables
vanilla Greek peanut butter
yogurt  2 T. low sodium
 ½ oz. mixed soy sauce
 Vegetable omelet seeds/nuts
(2 eggs and ½ c.  ½ c. shredded
cooked  ½ c. dried fruit low fat cheddar
vegetables) cheese
 ½ c. unsweetened
applesauce  Glass of water

 1 c. vegetable
juice

14. Now enter and assess the 1-day menu you planned for Jamey using the MyPlate Super Tracker online tool
(http://www.choosemyplate.gov/supertracker-tools/supertracker.html). Does your menu meet macro- and
micronutrient recommendations for Jamey?
a. *See Super tracker ‘View My Meal’ documents uploaded below for the macro- and micronutrient
breakdown of Jamey’s 1-day plan.
15. Why did Dr. Lambert order a lipid profile and blood glucose tests? What lipid and glucose levels are
considered altered (i.e., outside of normal limits) for the pediatric population? Evaluate Jamey’s lab results.
a. Lipid Profile is the standard cholesterol test that includes a total cholesterol, LDL, HDL,
triglycerides and VLDL test. Cholesterol contributes to hormone production, cell development
and nutrient absorption in addition to contributing to several health conditions. Dr. Lambert likely
ordered this test to measure Jamey’s cholesterol level as high cholesterol can lead to heart disease,
myocardial infarctions or stroke. Normal levels would be LDL less than 110-mg/dL or total
cholesterol less than 170 mg/dL. Jamey’s cholesterol came back at 165 mg/dL with LDL of 110
mg/dL right at the top of the range. Her results are likely due to her obesity but may also need to
consider testing for an underlying condition such as a thyroid condition.

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b. Cholesterol Levels in Children and Adolescents. (2015, December 3). Retrieved January 21, 2018,
from https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Cholesterol-Levels-
in-Children-and-Adolescents.aspx
c. Blood Glucose Tests measure the amount of glucose (sugar) in ones blood. Glucose is energy in
our bodies and our brains. Dr. Lambert likely ordered this test to screen Jamey for diabetes.
Normal range would be between 70-100 mg/dL. Jamey’s glucose came back at 112 mg/dL just
above the normal limit. Diabetes is a sign of high blood pressure and on the contrary, higher blood
pressure can be an indicator of the development of type 2 diabetes. Monitoring Jamey’s blood
sugars in addition to the amount of sweets she consumes are sure ways to eliminate the possibility
of diabetes.
d. Blood sugar test. (2017, April 15). Retrieved January 21, 2018, from
https://medlineplus.gov/ency/article/003482.htm
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?
a. Certain factors such as Jamey’s parent’s weights, eating and exercise habits would need to be
considered. The phrase “monkey see, monkey do” applies here where if her parents demonstrate
unhealthy eating habits and a sedentary lifestyle it is more likely for Jamey to do the same. In
addition, if Jamey’s family has a tendency to eat out at restaurants as opposed to cooking at home
that opens opportunity for unhealthier eating and higher fat or calorie content foods.
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?
a. I would not agree with this statement. Snacks are okay as long as they are reasonable and may
even be a better option than dessert. Although it is important for Jamey to understand and grasp
the importance of exercise I do not agree that it would be wise to reward her with sweet treats and
high fat foods each time she does. Minimizing sweet treats and dessert foods are one of the
several habits we would hope to eliminate during this process.
18. Identify one specific physical activity recommendation for Jamey.
a. Physical activity recommendation: slowly begin to incorporate minor physical activity into
Jamey’s schedule. For example, taking a walk around the neighborhood after school or dinner
with a pet or another family member for 20-30 minutes would be a good place to start. Encourage
Jamey to get involved with after school activities or sports to keep active as she continues to grow
and get older. Eventually, it would be most beneficial for Jamey to endure 45-60 minutes of
physical activity each day but for starters a good goal would be to achieve 20-30 minutes.
19. Select two nutrition problems and complete PES statements for each.
a. PES 1: Inadequate energy intake related to excess energy intake as evidenced by high BMI.
b. PES 2: Food and nutrition knowledge deficit related to lack of nutrition education as evidenced by
estimated intake more than need.
20. For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate
intervention (based on etiology).
a. PES 1: Inadequate energy intake related to excess energy intake as evidenced by high BMI.
i. Goal- Steady, healthy weight loss.
ii. Intervention- Create a meal plan for Jamey in addition to creating a plan for her parents
to reference when grocery shopping.
b. PES 2: Food and nutrition knowledge deficit related to lack of nutrition education as evidenced by
estimated intake more than need.
i. Goal- Improve knowledge of nutrition and beneficial foods to eat.

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ii. Intervention- Provide nutrition education to Jamey and her family on foods high in fats,
protein and carbohydrates. Review the concept of moderation when it comes to
unhealthier foods to limit.
21. Mr. and Mrs. Whitmer ask about using over-the-counter diet aids, specifically Alli (orlistat). What would
you tell them?
a. I would tell Mr. and Mrs. Whitmer that an over-the-counter diet aid is not necessary for Jamey at
this time. Due to her age I would advise against starting a diet aid so young as it would be wise to
explore other options, diet and exercise, first. As she gets older and if she remains unsuccessful
then a diet aid may be considered but not at this time.
22. Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey. Using the EAL, what are the
recommendations regarding gastric bypass surgery for the pediatric population?
a. Gastric bypass surgery is for patients who have tried and failed to lose weight. I don’t consider
Jamey to be suitable for this surgery especially considering her age. Although this surgery would
minimize her risk of developing diabetes, heart disease or depression she is not a candidate.
Candidates for this surgery need to have tried other weight loss programs and been unsuccessful,
have a BMI of 35 or more along with an obesity-related condition or a BMI of 40 or more without
an obesity-related condition. Although Jamey’s weight and BMI do qualify her as overweight she
is not obese and should attempt over weight loss options before jumping to surgery.
b. Weight-Loss Surgery (Bariatric Surgery) Program Contact number | 202-476-2151. (n.d.).
Retrieved January 26, 2018, from https://childrensnational.org/departments/bariatric-surgery-
program
23. What is the optimal length of weight management therapy for Jamey?
a. Weight management therapy for Jamey would include her losing 1-2 lbs./week. A gradual weight
loss with steady changes would be the best approach for her moving forward. Ideally, her gradual
weight loss and incorporating lifestyle changes steadily will help her keep off the weight more
than any crash diet or diet aids would.
24. Should her parents be included? Why or why not?
a. Yes, Jamey’s parents should be included in her weight management therapy because she is a minor
who still lives at home and their help and support will be most beneficial to her moving forward.
25. What would you assess during this follow-up counseling session?
a. During a follow-up counseling session I would discuss her weight loss progress, how she is
feeling physically and emotionally, as weight is a sensitive topic. I would also address her sleep
apnea to see if there has been any improvement in addition to acknowledging any personal goals
her or her parents have discussed since our previous meeting. Lastly, discuss her food intake and
assess if/how her habits have changed and how she in managing her calories and fat intake.

© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.