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Childhood Overweight I. 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) Genetics affects body weight and body composition by influencing such factors as appetite, taste preferences, energy intake, resting energy expenditure, the thermic effect of food, nonexercise activity thermogenesis (NEAT), and the bodys efficiency in storing energy. A child born to an obese parents are more likely to become obese than to one born to normal weight parents. Behavioralenvironmental (sedentary lifestyle, socioeconomic status, modernization, culture, and dietary intake) Sedentary lifestyle is influenced by increased availability and use of electronic media while decreasing physical activity. There is a lack of physical education programs in some public schools and sidewalks for safe walking in some neighborhoods. Daily activities that require walking or bicycling has been replaced with cars for even the shortest distances. Global (society, community, organizational, interpersonal, and individual) affects our behavior to food and encourages a high energy intake due to fast-food industry and convenient availability of low-cost, tasty, energy-dense foods, in large portion sizes. With growing fast-food industry, foods especially those high in fat with increased portion size are eaten away from home more in addition to snacking more often and drinking more sweetened drinks that are high in energy. Advertising and marketing influences food intake. Television and other media promote foods that are high in fat and sugar. Each factor influences the other correlating with each other making it difficult to conclude obesity is caused because of one thing and so it is multifactorial. (1,2,3) 2. List the health consequences associated with an overweight and obese condition. Heart disease Insulin resistance Type 2 diabetes Hypertension Dyslipidemia Gallbladder disease Asthma Sleep apnea Maturity-onset diabetes of youth (MODY) Cushings syndrome Hypothyroidism Polycystic ovary syndrome Prader-Willi syndrome Nonalcoholic fatty liver disease (NAFLD) (1,2) 3. Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea. Explain the relationship between sleep apnea and obesity.

Sleep apnea is a sleeping disorder characterized by periods of absence of breath that may last more than 10 seconds during sleep. Sleep apnea may impact appetite and can cause increased food intake and night eating which leads to obesity. (3) II. Understanding the Nutrition Therapy 5. List 6 recommendations for the nutritional treatment of Missys obesity. Increase physical activity like taking family walks, playing outdoor sports, bicycling, swimming, going to the park thus reducing sedentary activities like playing video games and watching television. Weight maintenance regulation of energy balance and body weight. Increase fruit and vegetable intake. Prevent more weight gain by making healthy food choices and appropriate portion size according to Missys age. Reduce high fat intake and calorie-dense beverages. Behavior therapy for Missy and her family and access potential barriers in trying to reach the goal. Give Missy and her family nutrition education on healthy eating, age appropriate portion sizes, healthy food preparation, healthy food purchasing, evaluation of nutrition labels, energy value of different foods, and medical complications of overeating. Missys family should be involved in all aspects of her treatment. Make her parents aware that they are responsible for proper emotional setting and they should be a role model in helping their child make right decisions about eating. (1,3) III. Nutrition Assessment A. Evaluation of Weight/Body Composition 7. Classify Missys weight using the CDC growth chart. According to CDC growth chart, Missy is placed in the 97th percentile for weight for age which classifies her as obese. B. Calculation of Nutrient Requirements 8. Calculate Missys energy requirement using the TEE for a 10 year old. TEE for Overweight Females Aged 3 18 yrs: height in meters, weight in kg. TEE = 389 - 41.2 x age + PA x 15.0 x wt + 701.6 x ht Age = 10 yr; PA = 1.0; wt = 52.3 kg; ht = 1.45 m = 389 41.2 x 10 + 1.00 x 15.0 x 52.3 + 701.6 x 1.45 = 1778.82 kcal (1) C. 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. Looking at her 24-hr recall, some of Missys increased dietary fat intakes are from burritos, bologna and cheese sandwiches with mayonnaise, Frito corn chips, twinkies, white bread, fried chicken, and mashed potatoes made with whole milk and butter, and fried okra. Some of kilocalorie-dense drinks she is consuming are whole milk, coffee w/ cream and sugar, sweet tea, and coco-cola.

Her total kcal = 4000 From the total calories: High fat food intake = 2600 kcal (65 % of total calories) Kilocalorie-dense drinks = 1000 kcal (25 % of total calories) (4) 10. Increased fruit and vegetable intake is associated with decreased risk of overweight. Using Missys usual intake, is Missys fruit and vegetable intake adequate? Why or why not? Missys fruit and vegetable intake is not adequate. From 24-hr recall, her only noted fruit and vegetable intake are 4-oz apple juice, 2 tbsp. grape jelly, 1 c mashed potatoes and 1 cup fried okra. These are especially high in either sugar or fat with little fruit or vegetable content. 11. Use the choosemyplate.gov online tool and plan a 1 day menu for Missy. A. On the choosemyplate.gov main page, you can click on the Get a personalized plan option or the Plan a healthy menu option this will help. Menu plan from choosemyplate.gov (attached on back) Missys recommended calorie intake should be approximately 1600 kcal for her age. When I made a days menu for her through choosemyplate.gov, it came close to that (about 1567 kcal) with more than the recommended 5 oz for meat. As much as I can I tried to include foods that she would like and are eating currently but with decreased fat. And also I eliminated her empty calorie beverages that she was consuming. (4) D. Clinical Domain 13. Why did Dr. Null order a lipid profile and a blood glucose test? A lipid profile would help determine the risk for heart disease in which it measures cholesterol, triglycerides, and HDL/LDL levels. A blood glucose test measures blood glucose level in the blood which determines risk for diabetes. Overweight and obesity are risk factors for high cholesterol and diabetes as well as family history of diabetes and high blood pressure. These factors put Missy at risk for having high blood cholesterol and diabetes which may cause many other health problems such as heart disease, or kidney disorders. (2) 14. What lipid and glucose levels are considered to be abnormal for the pediatric population? Cholesterol above 170 mg/dL, HDL less than 35 mg/dL, LDL above 110 mg/dL, TG above 150 mg/dL, and abnormal glucose level for children 5 to 11 years of age is considered to be less than 70 or above 150 mg/dL. Fasting blood glucose should be close to 70 mg/dL and after meals should be close to 150 mg/dL. (5,6) 15. Evaluate and explain the following regarding Missys lab results: Cholesterol 190 mg/dL is in the borderline level of between 170 - 199 mg/dL but is in close range to the high level of 200 mg/dL or above. She should strive to keep her cholesterol level in the desirable range which is below 170 mg/dL. This puts her at risk for multitude of health complications now and later in life. She should start to exercise and follow a low-fat diet. LDL 110 mg/dL is again in the borderline level of between 110 129 mg/dL and is in close range to the high level of 130 mg/dL or above. She should strive to keep her LDL level in the desirable range of less than 130 mg/dL. The borderline level indicates that

she could be at risk for other health complications such as heart disease. She should exercise and eat a balanced low-fat diet which includes more fruits and vegetables. Glucose 108 mg/dL (FBG) is not close to the desired level of 70 mg/dL after fasting. There is an increased risk for diabetes for Missy that could cause other medical complications. Exercising and eating a balanced diet that contains less sugar would improve her blood glucose levels (5,6)

E. BehavioralEnvironmental Domain 16. What behaviors associated with increased risk of overweight would you look for when assessing Missys and her familys diets? Behaviors such as any eating disorder with obesity, using food as a reward, eating pattern, food preparation methods, food frequency and portion sizes, meals eaten away from home, sources of high energy density, stress level and mood of Missy and her family as well as family activities. (1,3) 17. What aspects of Missys lifestyle place her at increased risk for overweight? Her school discontinued physical education program and she does not do any type of physical activity in her family which in itself is an increased risk for overweight. In addition Missy consumes more food than necessary for her age especially foods that are high in fat and sugar and low in vegetables and fruits. (1) 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? First of all, I would discourage them of using food as a reward but reward with other things that she might enjoy other than food or simply praise or give privileges that she might enjoy. Rewarding with food may send wrong messages such as eating when not hungry, overeating, and connecting food to mood. I would also let them know that snacking between meals are okay as long as they are providing a fruit, vegetable, or anything nutritious that are low in fat and sugar but not let her snack too often between meals. (7) 19. Identify one specific physical activity recommendation for Missy. I would recommend her to take brisk walks with her family starting with at least 3 times a week for 20-30 minutes. Later, they can gradually increase. (1) IV. Nutrition Diagnosis 22. Mr. and Mrs. Bloyd ask about using over-the-counter diet aids, specifically Alli (orlistat). What would you tell them? I would tell them that Alli is not recommended for children younger than 18 years of age and that there are many side effects in taking the drug such as stomach pain, nausea, and vomiting to name a few. Alli is a drug which blocks some of the dietary fat consumed and keeps it from being absorbed by your system thus helps in losing weight. It has to be used in conjunction with reduced-calorie diet and weight maintenance to treat obesity. (8) 23. 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 only for those who have severe obesity (BMI above 40), in those where weight loss was not successful. In children below 13, gastric bypass surgery is not recommended for they are not capable of making such complicated serious decision. There are many and serious complications that they may have to undergo and they may have to adhere to a strict diet though out their life. (9) Please turn in separately on a separate piece of paper to Dr. Imrhan on the due date of the case study. 20. Select one high-priority nutrition problem and complete PES statement. Excessive energy intake related to healthful food choices not provided as an option by parent as evidenced by patient consuming approximately 4000 kcal/day instead of the recommend level of approximately 1600 kcal/day for age. V. Nutrition Intervention 21. For the PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on etiology). Goal: 24-hour recall indicates patient consumes approximately 4000 kcal/day. Patients target calorie intake level is 1600-1700 kcal/day. Intervention: Recommendation of low-fat diet w/ increased consumption of fruits & vegetables. Recommendation to take brisk family walks at least 3x/wk. for 20-30 minutes. Educate the client and her family about correct portion sizes, sources of high energy foods, low-fat food choices and low-fat preparation methods, and overall on choosing & snacking healthy. Advise on keeping a food diary. 24. When should the next counseling session with Missy be scheduled? Next counseling should be done after 2 weeks to re-evaluate and to measure outcomes. 25. Should her parents be included? Why or why not? Yes, Missys parents should be included in all aspects of her treatment. Parents are responsible for proper emotional setting and they should be a role model in helping their child make right decisions about eating. 26. What would you assess during this follow-up counseling session? I would assess her weight and her food diary to see if there is any progress toward the recommended level of calories. Also, review the intervention plan to see if they are following recommendations and to see if changes are needed.

References: 1. Nelms MN, Sucher K, and Long S. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA: Wadsworth Cengage Learning; 2007. 2. Mahan LK, Escott-Stump S. Krauses Food and Nutrition Therapy. 12th ed. St. Louis, Missouri: Saunders Elsevier; 2008. 3. Escott-Stump S. Nutrition and Diagnosis-related Care Pittsburgh. 6th ed. PA, Williams & Wilkins; 2008. 4. USDA. Welcome to MyPyramid Menu Planner. Available at http://www.mypyramidtracker.gov/planner/launchPage.aspx. Accessed September 17, 2011. 5. Livestrong.com. Normal Level of Cholesterol for Children. Available at http://www.livestrong.com/article/23046-normal-level-cholesterol-children/. Accessed September 17, 2011. 6. Livestrong.com. What Are Healthy Glucose Levels in Children? Available at http://www.livestrong.com/article/28521-glucose-levels-children/. Accessed September 18, 2011. 7. Better School Food. Using Food as a Reward-Why it is Sending the Wrong Message to our Kids. Available at http://www.betterschoolfood.org/downloads/resources/BSF_Food_Rewards.pdf. Accessed September 18, 2011. 8. Drugs.com. Alli. Available at http://www.drugs.com/alli.html. Accessed September 19, 2011. 9. Pediatrics. Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations. Available at http://www.pediatricsdigest.mobi/content/114/1/217.full. Accessed 20, 2011.