Questions:-

1. Disease & Pathophysiology

Current research indicates that the cause of childhood obesity is multifactorial. Briefly discuss how
the following factors are thought to play a role in development of childhood obesity pertaining to the
current case

GENETICS
Gene studies have led to the identification of seven monogenic disorders. But, these disorders only account
for 7% of patients). Many other obese patients have a history of early-onset obesity inherited in a
Mendelian manner or have sub-phenotypes that overlap with the monogenic obesity syndromes, implying
that there are many other genes and gene products to identify.
Human food intake is not an entirely voluntarily controllable phenomenon, as it is controlled powerful
biochemical signals. The genetic defects found to date all affect the drive to eat, resulting in hyperphagia
in affected subjects.
Knowledge of gene-environment interaction will increasingly play a role in the improved targeting of
behavioural interventions for the prevention of obesity. (Branten., et al, 2013)

LIFESTYLE
The key lifestyle factors that lead to obesity are
 Increased use of mechanisation,
 Usage of gadgets in play time i.e. reduced outdoor game time,
 Overconsumption of HFSS foods,
 Increased familial habit of eating out often,
 Increased pocket money provided to children,
 Reduction in physical activity time in schools,
 More time in front of TV or in social media,

In a nut shell, all these lead to a sedentary lifestyle with very less physical activity. Whereas on
the other hand, increased calorie consumption causes a positive energy balance leading to obesity.

MODERNISATION

Increased mechanisation of everyday activities has significantly reduced energy expenditure as

mentioned earlier leading to obesity. Gadgets and apps are available for anything and everything. Even a
child can order food through online portals or hire a car. It has become so easy and inexpensive.

CULTURAL
Indian food culture from ages has been an amalgamation of fasting and feasting. We associate food with
each and every event, festivals, childbirth, death, harvest etc.

Traditionally made food was nutritionally balanced and in earlier days people lead a healthy life because of
high levels of physical activity. But now, because of decreased levels of physical activity, the foods that well
suited us before are being of concern now a days.
And there is a wrong notion among the population that all vegetarian foods are good for health and can be
consumed in any quantity. What is not considered is the amount and quality of then food consumed.

ENVIRONMENTAL

An obesogenic environment is one among the major factors leading to obesity of any age.
Children are bombarded from all possible ways of marketing and advertising i.e. through mass media, social
media with various kinds of unhealthy packaged foods and drinks. Their young mind shaped from a very
small age to reach out for these snacks whenever they see them in shops.

On the other hand, even though nutrition is a part of science education in our curriculum because of the lack
of link between school and home, real eating habits are not cultivated via education.

Parents also play an important role in deciding what kind of environment the child will be exposed in the
early stages of life wherein food choices of the kids are made by the parents themselves.

2. Nutrition therapy
What would you recommend as the current focus of nutritional treatment for Miss XYZ?
Weight management will the current focus of nutrition treatment, because in this case sleep apnea in itself
is attributed to overweight status of the child.

List the foods to be avoided and included?

 Packaged food, bottled drinks (both carbonated and fruit based), deep fried foods and snacks.
 In a nut shell, all HFSS foods should be avoided.

 Fresh fruits, vegetables and nuts, raw or cooked at home with less amount of oil should be included.

3. Nutrition assessment
Evaluate Ms. XYZ weight using CDC growth chart, what is her BMI percentile? How do you assess
her anthropometric status and classify it based on standards?
 The child’s BMI is 25.5kg/ m2. It is greater than 95th percentile thus she is obese.
 The anthropometric status is assessed by taking her height, weight and thus calculating BMI.

Calculate the energy requirement using Harris Benedict equation

BMR = 655.1 + (9.563 × weight in kg) + (1.850 × height in cm) – ( 4.676 × age in years )
= 655.1 + 478.15 + 259- 46.76
= 1,345.49 kcal
Considering the sedentary lifestyle activity factor is 1.2
Total energy requirement = 1,615 k cal

Calculate the energy requirement using Miffin St. Jeor’s equation

BMR = (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) – 161
= 500 + 875-50-161
= 1164 k cal
Considering activity factor 1.2,
Total energy requirement = 1397 k cal

State the RDA for energy and protein

RDA for energy = 2010 k cal

RDA for protein = 40.4 g
4.Nutrition diagnosis
Intake Domain: “Increased fruits and vegetables intake is associated with reduced risk of obesity”:-
based on the diet history comment on the intake of fruits and vegetables and justify the above
statement with appropriate scientific evidence.
Obesity in most cases is associated with a positive energy balance mainly caused by the consumption of
high energy food. Whereas all the fruits and vegetables contain very less amount of calories and have a good
amount of fibre that helps in keeping the satiety level thus helping the subject in avoiding over eating and
thus helps in weight reduction and management.

Intake Domain: Identify the foods from the diet which predisposes Ms. XYZ to obesity
 Fruit juice, fried snack, potato wafers, khakra chat
 Cheese (if processed) and sandwich if made from white bread
 Buffalo milk (If full fat and consumed with added sugar) are predisposing the child to obesity

Clinical domain: Why has the doctor asked for BG test in this case? Justify.
Since there is maternal gestational diabetes and a family history of diabetes is evident in this case, the doctor
ordered for a BG test.
Justification:
As studies suggest that children born to mothers with a prior history of gestational diabetes mellitus and
obesity are at significantly greater risk of developing metabolic syndrome themselves as a child or later in
adulthood

Clinical domain: Explain the relationship between obesity and sleep apnea in this case
The most common cause of obstructive sleep apnea is excess weight and obesity, which is associated with soft
tissue of the mouth and throat. During sleep, when throat and tongue muscles are more relaxed, this soft tissue
can cause the airway to become blocked thus causing the cessation of breath in episodes lasting upto10 seconds.

Behavioural Domain: What aspects of her lifestyle have increased the risk of obesity?
 Physical in activity
 consumption of calorie dense HFSS foods

Behavioural Domain: You speak to the patients parents, they are friendly and co=operative. Patient’s
mother asks if it would help them if they do not allow the child to snack between meals and reward
her with her favourite dessert when she exercises. What will be your response? - justify
Yes, I will allow the mother to do what she wants as she is the one who knows her child better.
But what I will educate her is about the portion size and frequency of the reward.i.e. The favourite dessert.
And also it is scientifically proven that reward systems work.
That is the reason why even adults on a diet regime let themselves have cheat meals and cheat days once in a
while.

Select 2 high priority nutrition problem and write the PES statement for both
 Overweight status (P) because of sedentary lifestyle (E) as evidenced by less physical activity(S)
 Overweight status (P) because of excess calorie consumption (E) as evidenced by overconsumption
of fried foods(s)

Nutrition Intervention
For each PES statement establish an ideal short term and long term goal
For both the PES statements,
Short term goal
 To improve the physical activity level of the child
 To reduce the consumption of fried foods
 To incorporate more fruits and vegetables in the diet
  Long term goal
 Weight reduction to the standard requirements and weight management

Nutrition monitoring and evaluation

List what all would you assess during follow up counselling process?
 The emotional status of the child, of how she is coping up with the present changes in her diet
 If she is engaging in enough physical activity
 Her height and weight and the subsequent plotting of CDC growth charts and further follow up

Write the ways of measuring outcomes for anthropometry for this case

Assessment of the CDC growth charts with the height and weight of the kid will tell us if the child is doing
well or not through the percentiles mentioned.