Kayla Kmet Lora Lee Aaron Rebecca Willis Stephanie Hunley
Case Study 1 Missy Bloyd’s Story 10/28/09
Name: Missy Bloyd Birth: 10/9
•Client •Date •Age:
Female (5th grade) Less than high school n: Student
•Sex: •Education: •Occupatio
• • • • •
Hours of Work: Regular school hours Household members: Father (36), mother (35), sister (5) Ethnic Background: Biracial (African American and Caucasian) Religious Affiliation: Catholic Referring Physician: D. Null, MD
• • • • • • •
Sleep disturbance in last several yearssleeping with mouth open, cessation of breathing for 10 sec, snoring, restlessness, enuresis, morning headaches Changes in school grades/success Change in attention span Onset: unspecific, about a year ago Tx: none Meds: none Smoker: no Family Hx:gestational diabetes, type 2 DM, in mother and grandmother
Height: 57 in Weight: 115 lbs Percentile: 98th BMI: 24.95 • According to the CDC, overweight in children 2-19 yo. is classified as being at or above a BMI in the 85th percentile. Obesity in 2-19 yo. is defined as being at or above a BMI in the 95th percentile. • For every five point increase in BMI a person enters a higher bracket of disease risk. The diseases and conditions do not necessarily increase in number, but in likelihood • Overweight and obesity can come with several co morbidities and complications including: diabetes, gall bladder disease, hypertension, dyslipidaemia (too much fat in the blood), sleep apnea, coronary heart disease, osteoarthritis (deterioration of cartilage in knees), hyperuricaemia (too much uric acid in the blood) which may result in gout (swelling in feet from deposited uric acid), cancer, reproductive, hormone abnormalities, polycystic ovarian syndrome, impaired fertility, low back pain, increased anaesthetic risk (loss of sensation or consciousness), and fetal defects from maternal obesity.
“We’ve noticed that Missy appears to stop breathing for several seconds several times a night. She is really cranky when she gets up for school. Her teacher says Missy gets very sleepy during school...She fell asleep in class yesterday.”
Missy’s Nutritional Hx
• • • • •
General: very good appetite, wide vatiety of food Food allergies/intolerances: NKA Previous Nutrition Therapy? No Food Purchase/Preparation: Parent(s) Vit/Min Intake: Flintstones vitamin daily
24 Hour Recall
AM: 2 breakfast burritos, 8oz whole milk, 4oz apple juice, 6oz coffee with 1/4 c cream and tsp sugar LUNCH: 2 bologna and cheese sandwiches with 1tbsp of mayo, 1 oz package Frito corn chips, 2 twinkies, 8 oz whole milk
24 Hour Recall
AFTER SCHOOL SNACK: Peanut butter and jelly sandwich (2 slices enriched bread with 2 tbsp crunch peanut butter and 2 tbsp grape jelly), 12 oz whole milk DINNER: Fried chicken (2 legs and 1 thigh), 1 c mashed potatoes (whole milk/butter), 1 c fried okra, 20 oz sweet tea SNACK: 3 c microwave popcorn, 12 oz Coca-Cola
R/O Obstructive Sleep Apnea (OSA) secondary to obesity and physical activity OSA: Sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep. There are two types of sleep apnea: central and obstructive. Central sleep apnea occurs when the brain fails to send the appropriate signals to the breathing muscles to initiate respirations. Obstructive sleep apnea occurs when air cannot flow into or out of the person's nose or mouth although efforts to breathe continue.
• • • • • •
Polysomnography FBG HbA1C Lipid Panel Psychological Evaluation Nutrition Assesment
Two Part Analysis
•Testing •Lab Results
•Blood Glucose Test
-Helps to determine whether individuals are hyperglycemic, hypoglycemic, or if individuals have diabetes
-Helps to determine whether there is a risk for heart disease by measuring cholesterol, triglycerides, HDL, and LDL levels.
Blood Glucose Levels
•Missy’s Blood Glucose Level- 108 mg/dL
•Normal Levels- 70-110 mg/dL
Prediabetes- 100 mg/dL Diagnosis of Diabetes- 100-126 mg/dL
Evaluation of Missy’s Blood Glucose Level
Missy’s Blood Glucose Level- 108 mg/dL
• -Her current level places her in the higher end of the normal range and in the prediabetes area.
• -weight, poor insulin circulation, over consumption of carbohydrates
Cholesterol LDL HDL TG
Missy’s Lipid Profile Results
190 110 50 114
Evaluation of Missy’s Lipid Profile
• • • •
Normal Levels Levels
LDL- <130mg/dL HDL- >55mg/dL TG- 35-135mg/dL
190mg/dL 110mg/dL 50mg/dL 114mg/dL
Physical Activity Level- sedentary -Includes reading and playing video
• • • • • • • • • • • •
EER for Girls 9 Through 18 Years EER = TEE + energy deposition EER = 135.3 − (30.8 × age [y]) + PA × (10.0 × weight [kg] + 934 × height [m]) + 25 kcal Where PA is the physical activity coefficient: PA = 1.00 if PAL is estimated to be ≥ 1.0 < 1.4 (sedentary) PA = 1.16 if PAL is estimated to be ≥ 1.4 < 1.6 (low active) PA = 1.31 if PAL is estimated to be ≥ 1.6 < 1.9 (active) PA = 1.56 if PAL is estimated to be ≥ 1.9 < 2.5 (very active) Missy: Age 10 yrs PA 1.0 Weight kg=52.3 Height m= 1.45 EER= 135.3- (30.8 x10) + 1.0 x (10.0 x 52.3kg + 934x 1.45m) + 25 kcal EER= 135.3- 308 + 1.0 x 1877.3 + 25kcal EER= 1729.6 kcal
• 1729.6 kcal
• -includes high fat and high starch foods with inadequate fruit and vegetable intake
• Total calories= 4435 kcals • Energy dense beverages= 402 kcals • High fat foods= 2697 kcals
9.06% of total calories
60.81 % of total calories
Energy Intake- High fat and high carbohydrate
content of food with a low energy output.
Blood Glucose Test- Due to her weight and
high carbohydrate consumption her insulin levels are not keeping up with her blood glucose levels, which places her at risk for type II diabetes.
Lipid Profile- Elevated levels indicate she is at
risk for developing cardiovascular disease as well.
Missy’s Diagnosis and Treatment Plan
Missy’s Nutrition Diagnosis ~ PES
• Excessive energy intake related to energy-dense food choices as evidenced by estimated energy intake of 4,435 kcals based on 24 hour recall. • Physical inactivity related to preference for sedentary activities as evidenced by report of enjoying video games and reading.
Missy’s Nutrition Intervention-Based on PES statements 1) Excessive energy intake.
• Goal: for Missy to achieve appropriate energy intake levels. • Intervention: nutrition education for Missy and her parents covering:
• • • •
Portion Control Balancing intake based on physical activity level Healthy cooking techniques/ meal and snack ideas Health risks of chronic overweight
Missy’s Nutrition Intervention-Based on PES statements 2) Physical Inactivity.
• Goal: to increase Missy’s physical activity. • Intervention: encourage her to play more outside the house, in addition, we recommend that she enroll in an after school sports program of her choice (soccer, basketball, volleyball, swimming, etc) so that she can be more active and enjoy it. • Also, we recommend Missy get a Wii system so she can be more active during her screen time.
Day 1 Breakfast
1% milk (low fat) Oatmeal (plain) • 1% milk (low fat) Blueberries (raw)
Fat free milk (skim) Wrap sandwich (meat, vegetables, rice)
• • •
Fat free milk (skim) Chicken, veggies & noodles (cream sauce) Raw carrots
• Creamy dressing (ranch)
Wheat roll (part whole wheat)
• • •
Banana Lowfat cottage cheese Cucumber
• Italian dressing (oil and vinegar)
Canned tuna (in oil)
Missy’s Menu Assessment
Monitoring and Evaluation
Next counseling session for Missy should be scheduled as soon as possible, needs to get appropriate treatment for sleep apnea and then start Nutrition counseling immediately. Her parents should definitely be included in her counseling sessions, they are preparing her meals. In follow up visit, assess short term goals that were originally set, these are first steps to her long term goals. We would assess any changes in physical activity and dietary behavior.
Missy’s Lifestyle and Our Culture
What put Missy at risk for becoming overweight? Childhood Obesity~ Causes
• Genetics • Behavioral/environmental • Global trends/ Personal Habits
Missy’s Weight Loss Options
• Not For Children
Gastric Bypass Surgery
• Not For Children
Healthy Diet and Physical Activity
• Appropriate for Anyone
Missy and Her Peers
Goals for pediatric weight loss
• Who is involved?
Family Food Diary Portion Control Healthier eating choices More physical activity/less sedentary activity
• What are they eating?
• Weight management