Download File - Medical Nutrition Therapy Manual

Lauren Farmer
KNH 411
Case Study #1
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); behavioral-environmental
(sedentary lifestyle, socioeconomic status, modernization, culture, and dietary intake);
and global (society, community, organizational, interpersonal, and individual).
Biological factors that play a role in the development of childhood obesity include
the individual’s genetics. It affects body weight and body composition by
influencing such factors as appetite, taste preferences, energy intake, resting
energy expenditure, the thermic effect of food, and body’s efficiency in storing
energy. Obesity is not inherited in a predictable manner, which complicates our
understanding of the etiologic role of genetics. Having obese family members
does increase an individual’s risk of becoming obese as well. This indicates that
multiple genes are involved in making small contributions to an individual’s body
weight and how they respond to environmental factors, such as diet, physical
activity, and culture (Nelms 257). Behavioral-environment also plays a role in the
development of obesity. Behaviors such as decreased or lack of physical activity,
excess caloric intake, increased portion sizes, and unhealthy snacking throughout
the day. In Missy’s case, her school decreased the student’s exposure of physical
activity during the school day by cutting out PE classes. Also, global factors can
aid in the development of obesity. Examples include the fast paced nature of our
society and the media. The media plays a vast role by producing commercials of
unhealthy foods and so.
2. Describe the health consequences associated with an overweight condition. Describe
how these health consequences differ for an overweight versus an obese condition.
The term overweight is used to indicate the excess of weight in an individual,
above what is considered normal for their height, age, and sex. This means that
their BMI is between 25 and 29.9kg/m2. Being overweight may result from
overeating, having a sedentary lifestyle, little to no exercise, or a medical
condition. It can be characterized with/lead to depression, high blood pressure,
glucose intolerance, elevated LDL and/or triglycerides, and an increased risk of
type 2 diabetes and hypertension. On the other hand, obesity is referred to as
excessive fat. Bodily condition marked by excessive generalized deposition and
storage of fat, with a BMI over 30kg/m2. The same factors that lead to being
overweight also lead to obesity, along with social and lifestyle changes, medical
issues, hormonal imbalance, and genetic conditions. Risk factors include
depression, coronary heart disease, type 2 diabetes, hypertension, hyperlipidemia,
and metabolic syndrome. The health risks and consequences increase with the
presence of obesity. The more a person weighs is directly proportional with their
chances of obtaining these health problems. Both overweight and obese
individuals increase their risk of shortening their life span and become more
susceptible to illness and disease.
Obese vs. Overweight. (n.d). Diffen. Retrieved October 12, 2014, from
http://www.diffen.com/difference/Obesity_vs_Overweight.
3. Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea. Explain the
relationship between sleep apnea and obesity.
Sleep apnea is a common disorder in which an individual’s breathing is
interrupted while they sleep. Obstructive sleep apnea (OSA), what Missy was
diagnosed with is the more common form of sleep apnea that is caused by a
blockage in the airway. In this disorder, breathing repeatedly stops and starts.
Missy’s parents reported that she appears to stop breathing for several seconds
(approximately 10 seconds per episode) several times a night. They also indicate
that Missy sleeps with her mouth open, snores, and is restless during sleeping. She
is also tired and cranky when she gets up in the morning and complains of a
headache. All of these factors are associated with OSA. One of the most common
causes of obstructive sleep apnea in adults and children is obesity. Sleep apnea
severity increases with weight gain. It is associated with an excess of soft tissue of
the mouth and throat. When an individual sleeps their throat and tongue muscles
become relaxed and can cause the airway to become blocked. A good predictor of
sleep apnea is an individual’s neck circumference. Males are more likely to have
sleep apnea if their neck circumference is 17 inches or larger and 16 inches or
larger in females.
Derrer, David. (2014). Sleep Apnea. WebMD. Retrieved October 9, 2014, from
http://www.webmd.com/sleep-disorders/sleep-apnea/sleep-apnea.
Karriem-Norwood, Varnada. (2014). Causes of Obstructive Sleep Apnea.
WebMD. Retrieved October 9, 2014, from http://www.webmd.com/sleepdisorders/sleep-apnea/obstructive-sleep-apnea-causes.
Heit, Jeffrey. (2008). Obesity and Sleep Apnea: What’s the Connection?. Health
Central. Retrieved October 9, 2014, from
http://www.healthcentral.com/obesity/c/45116/38444/obesity-connection.
II.
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?
The goals for weight loss in the pediatric population is for an individual to be at or
under the 85th percentile, ensure that the child grows and develops at a normal
range, and to aid the child in reaching a healthy weight. Weight loss in the
pediatric population can be a touchy subject. Children need calories for growth
and development. These calories are also required for daily metabolism and
physical activity. For this reason, their calories should not be cut too much. It is
not appropriate for overweight children to lose weight if they are still very young.
Children should be given time to grow and develop. In most cases, children level
out their weight as they age and go through puberty. Maintaining weight allows
children to grow into a healthy weight. However, extreme circumstances do occur
and should be addressed with a doctor.
Weight-Loss Recommendations for Children. (n.d.). Weight Watchers. Retrieved
October 12, 2014, from
http://www.weightwatchers.com/util/art/index_art.aspx?tabnum=1&art_id=23571
5. What would you recommend as the current focus for nutritional treatment of Missy’s
obesity?
The focus for Missy’s current nutritional treatment should be on her excessive
caloric intake, specifically looking into those coming from fat. According to
Missy’s 24-hour recall, I would recommend limiting her intake of fried foods,
whole milk, fatty meats, and spreads, while focusing on incorporating more fresh
fruits and vegetables, whole grains to increase fiber, and water. Another main
focus would be on her snacking habits. I would also want to recommend more
appropriate snack for Missy. Instead on 3 cups of popcorn and 12 oz of CocaCola, I would suggest options such as fruit or vegetables and water. Also,
affirming them that they are correct in providing her with 3 meals and 2 snacks a
day. Along the way Missy and her family would become more educated on living
a healthier lifestyle.
III.
A.
Nutrition Assessment
Evaluation of Weight/Body Composition
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.
 Centers for Disease Control and Prevention (CDC) Growth Charts:
o Overweight is defined as having a BMI-for-age at or above the 85th
percentile and lower than the 95th percentile for children of the same age
and sex. This is determined by using height, weight, age, and gender.
 Academy of Nutrition and Dietetics
o Having a BMI between 25.0 and 29.9 kg/m2
 International Obesity Task Force (IOTF)
o Having a BMI between 23 and 25 kg/m2
Basics about Childhood Obesity. (2012). Centers for Disease Control and
Prevention. Retrieved October 12, 2014, from
http://www.cdc.gov/obesity/childhood/basics.html.
Defining Overweight and Obese. (2012). Academy of Nutrition and Dietetics.
Retrieved October 12, 2014, from
http://www.eatright.org/Public/content.aspx?id=6845.
The Global Challenge of Obesity and the International Obesity Task Force.
(n.d.). International Union of Nutritional Sciences. Retrieved October 9, 2014,
from http://www.iuns.org/the-global-challenge-of-obesity-and-theinternational-obesity-task-force.
7. Evaluate Missy’s weight using the CDC growth charts provided. What is Missy’s BMI
percentile? How would her weight status be classified by each of the standards you
identified in question 6?
Missy’s BMI: 115lb/(57in2)x703 = 24.9 or 25kg/m2 identifying her as overweight
Her BMI percentile is >97th percentile
According to the standards that look into BMI calculations, Missy is considered to
be in the overweight range. However, her weight status according to the growth
charts classify her as obese.
B.
Calculation of Nutrient Requirements
8. If possible, RMR should be measured by indirect calorimetry. Identify two methods for
determining Missy’s energy requirements other than indirect calorimetry and then use
them to calculate Missy’s energy requirements.
Mifflin-St. Jeor: 10x(52.3kg)+6.25x(144.8cm)-5x(10yrs)-161
523 + 905 – 50 – 161 = 1217 kcal/day
Quick Estimate: 52.3kg x 23 = 1203 kcal/day
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 Missy’s diet recall
that fit these criteria. Calculate the percentage of kilocalories from each macronutrient
and the percentage of kilocalories provided by fluids for Missy’s 24-hour recall.
Foods from Missy’s diet recall that are high in fat include whole milk, coffee
cream, bologna, mayonnaise, Frito chips, Twinkies, fried chicken, fried okra, and
mashed potatoes since they were made with whole milk and butter. The increased
calorie dense beverages in Missy’s diet include her consumption of whole milk,
sweet tea, and Coca-Cola. According to Missy’s 24-hour recall and using
SuperTracker to assess her diet, she consumed 5,025 kcal. Percentage of
kilocalories from macronutrients and fluids are as follows:
 Carbohydrates: 43%
 Protein: 15%
 Fat: 42%
 Fluid: 18%
10. Increased fruit and vegetable intake is associated with decreased risk of overweight.
Using Missy’s usual intake, is Missy’s fruit and vegetable intake adequate?
Looking at Missy’s 24-hour recall, she does not meet adequate intake of fruits and
vegetables, also appearing to be deficient with her consumption. The only
presence of fruits and vegetables from her 24-hour recall was 4 ounces of apple
juice, 2 tablespoons grape jelly, and 1 cup fried okra. According to
ChooseMyPlate.gov, girls 9-13 years old should consume approximately 2 cups
of vegetables and 1 ½ cups of fruit per day. These items aren’t sufficient enough
to meet her recommended needs.
How Many Vegetables Are Needed Daily or Weekly?. (n.d.). USDA
ChooseMyPlate.gov. Retrieved September 9, 2014, from
http://www.choosemyplate.gov/printpages/MyPlateFoodGroups/Vegetables/foodgroups.vegetables-amount.pdf.
How Much Fruit is Needed Daily?. (n.d.). USDA ChooseMyPlate.gov. Retrieved
September 9, 2014, from
http://www.choosemyplate.gov/printpages/MyPlateFoodGroups/Fruits/foodgroups.fruits-amount.pdf.
11. Use the ChooseMyPlate online tool (www.choosemyplate.gov; click on “daily food
plans” under “Popular Topics”) to generate a personalized daily food plan for Missy.
Using this eating pattern, plan a 1-day menu for Missy.
The following is the generated personalized daily food plan for Missy, following
a 1,600 kcal/day diet:
 5 oz. grain
 2 cups vegetables
 1 ½ cup fruit
 3 cups dairy
 5 oz. protein
The following tips were also provided:



Make half your grains whole – aim for at least 3 oz. whole grains/day
Vary your vegetables – alternate between different colors and textures
Oils and empty calories – aim for 5 tsp. oils/day and limit empty calories
(extra fats and sugars) to 120 calories
Breakfast
Lunch
After-school
snack
Dinner
PM Snack
2 slices of
whole wheat
bread
1 whole wheat
tortilla wrap
1 cup vanilla
yogurt
2 oz grilled
chicken breast
1 cup grapes
2 tbsp sugar
free grape jelly
2 slices turkey
breast
1 cup celery
stalks
½ cup broccoli
water
1 scrambled egg 1 cup spinach
2 tbsp peanut
butter
1 orange (slices) 2 tbsp lite ranch water
dressing
8 oz skim milk
1 medium
sweet potato
8 oz skim milk
1 oz bag
pretzels
water
*I didn’t include an AM snack between breakfast and lunch due to the fact that Missy is
typically in school during that time.
12. Now enter and access the 1-day menu you planned for Missy using the MyPlate
SuperTracker online tool (www.choosemyplate.gov/supertrackertools/supertracker.html). Does your menu meet macro- and micronutrient
recommendations for Missy?
The 1-day menu I planned for Missy does meet macro- and micronutrient
recommendations for Missy. The menu I created incorporated 5 oz. grains, 2 ¼
cup vegetables, 1 ¾ cup fruit, 3 cups dairy, and 6 oz. protein. The majority of
micronutrients were meet with her recommendations. Ones that may need to be
watched is sodium, iron, potassium, vitamin D, and E. All other vitamins and
minerals were at recommended standings. Also, the 1-day menu came to 1,584
kcal with the goal being 1,600 kcal.
D.
Clinical Domain
13. Why did Dr. Null order a lipid profile and a blood glucose test?
A lipid profile is used as a screening tool for measuring the lipids in an
individual’s blood. It includes serum cholesterol, HDL, LDL, and serum
triglycerides (Nelms 320). Dr. Null ordered a lipid profile to analyze the amount
of fat in Missy’s blood. Its assessment of fat metabolism is important in
identifying potentially dangerous high levels of lipids and LDL cholesterol which
can lead to numerous heart health concerns for Missy. A blood glucose test
measures the amount of glucose (sugar) in the bloodstream. Dr. Null also ordered
the blood glucose test for Missy because she shows signs of developing and has a
family history of diabetes. Her mother and grandmother both have type 2 diabetes
and possible gestational diabetes.
14. What lipid and glucose levels are considered to be abnormal for the pediatric
population?
Normal lipid levels are as follows: total cholesterol 120-199 mg/dL, HDL > 55
mg/dL, LDL < 130 mg/dL, and triglycerides 35-135 mg/dL. Whereas, glucose
levels that are considered normal are 60-100 mg/dL. Abnormal levels for the
pediatric population would be anything outside of these designated ranges.
15. Evaluate Missy’s lab results.
Looking at Missy’s lab results, it is noticed that most of her levels are technically
within range of the normal standards but lean toward the low to high ends of the
recommendations. It was seen that her cholesterol was borderline high at 190
mg/dL where 199 mg/dL is the upper range. Her HDL was not high enough with
over 55 mg/dL as the recommendation, her level was at 50 mg/dL. However, her
LDL/HDL ratio was in normal standings at 2.2 with < 3.22 as the
recommendation. A1C levels came back as high with 3.9-5.2% being considered
normal, Missy’s was at 5.5%. This lab result is important because it can be used
as an indicator for diabetes. The high A1C readings could mean that Missy has
diabetes. Her glucose was borderline high at 108 mg/dL where 70-110 mg/dL is
normal, along with her borderline high calcium level of 9.2 mg/dL with the
normal range being 9-11 mg/dL.
E.
Behavioral-Environmental Domain
16. What behaviors associated with increased risk of overweight would you look for when
assessing Missy’s and her family’s diets?
When assessing Missy’s increased risk of being overweight, I would look into her
and her family’s diet. By looking over her 24-hour recall, the first factor that
needs to be addressed is the high prevalence of fatty foods. Such foods as whole
milk, bologna and mayonnaise sandwiches, Frito corn chips, Twinkies, and fried
chicken to name a few. The family’s diet is also high in processed foods with are
very high in sodium. Missy also consumes too large of portions for her age. It
appears that her diet is high in sugars and saturated fats as well. As mentioned
previously, her diet contains little to no fruits and vegetables.
17. What aspects of Missy’s lifestyle place her at increased risk for overweight?
There are multiple factors in Missy’s lifestyle that place her at increases risk for
overweight. It is indicated within her medical record that she lives sedentary
lifestyle which is generally low in physical activity. She likes playing video
games and reading. Both of these activities combined with her poor diet are
examples of her risk for being overweight. It does not help that her school
discontinued their physical education classes due to budget cuts within the past
few years. That means Missy does not get the required amount of physical activity
she needs in a day through her hobbies of reading and playing video games and
has not received it while at school for the past 5 years.
18. You talk with Missy and her parents. They are all friendly and cooperative. Missy’s
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 inform Missy’s parents that snacking between meals is recommended, as
long as the snacks are healthy and nutritious. The addition of small snacks
between meals is important in aiding the prevention of over eating during the 3
major meals of the day. It can also help increase nutritive intake. In fact, snack
time would be a good opportunity to add fruits and vegetables into Missy’s diet.
Rewarding a child with food for doing any type of activity is not a good decision.
So when it comes to rewarding Missy with dessert after exercising, it may prove
to be contradictory if the post workout dessert was high in calories, sugar, or fat.
Missy can consume a snack before or after exercise but only one that is nutritious
and will benefit her. If she is rewarded with dessert for exercise, she will begin to
associate physical activity with consuming food, which can be an unhealthy habit.
I would tell her parents that goal and reward setting is a technique used with
patients trying to make a lifestyle change. I would recommend to them to use
encouragement and make palpable rewards such as a new toy after completing a
certain achievable goal for Missy.
19. Identify one specific physical activity recommendation for Missy.
If Missy doesn’t already have a bicycle, I would recommend her family to invest
in one for her. This would be a fun activity for Missy to do after school or on the
weekends for 30 minutes daily. To make the situation even better, is if her whole
family had bicycles and could make it a family activity. They could bike around
their neighborhood or make a trip out of it and explore their town.
IV.
Nutrition Diagnosis
20. Select two high-priority nutrition problems and complete PES statements for each.
1) Overweight related to excessive caloric intake as evidenced by BMI of 25
kg/m2.
2) Excessive fat intake related to over consumption of high fat foods as
evidenced by the 24-hour recall.
V.
Nutrition Intervention
21. For each PES statement written, establish an ideal goal (based on signs and symptoms)
and an appropriate intervention (based on etiology).
1) Goal: Increase physical activity and reduce BMI to a healthy range.
Intervention: Increase Missy’s physical activity to 30 minutes a day while
reducing her overall caloric intake by 500 kcal/day in order to lose 1 lb/week.
2) Goal: Reduce intake of bad dietary fats and bring HDL, LDL, and overall
cholesterol to normal standards.
Intervention: Educate Missy and her family on consuming healthier and low
fat foods and to reduce her cholesterol to < 200 mg/dL.
22. Mr. and Mrs. Bloyd ask about using over-the-counter diet aids, specifically Alli (orlistat).
What would you tell them?
I would tell Mr. and Mrs. Bloyd that I do not recommend the use of over-thecounter diet aids for Missy. When it comes to diet aids, there are multiple risk
factors that have to be taken in consideration. Most of the time, the risks out way
the benefits. Addressing their suggestion of Alli, which is a fat fighting diet aid. It
promotes weight loss by decreasing the absorption of fat in the body, which
reduces the number of calories that are absorbed. Alli may also interfere with the
absorption of vitamin A, D, E, and K. These specific vitamins are essential in the
growth and development of children. This over-the-counter diet aid is approved
for overweight individuals over the age of 18. This would not be suitable for
Missy and may produce more harm than good to her growing body. I would
recommend that we first try to make necessary changes to Missy’s diet and
increase her physical activity. Those changes should be enough of a start for
Missy right now. The key to safe and appropriate weight loss is a healthy
balanced diet with physical activity.
Alli Weight-Loss Pill: Does it Work?. (2012). Mayo Clinic. Retrieved October 12,
2014, from http://www.mayoclinic.org/healthy-living/weight-loss/indepth/alli/art-20047908.
23. Mr. and Mrs. Bloyd ask about gastric bypass surgery for Missy. What are the
recommendations regarding gastric bypass surgery for the pediatric population?
Roux-en-Y procedure creates a very small pouch after gastric resection and
connects the jejunum to the upper portion of the stomach. This will allow food to
travel down the throat, into the pouch, and then directly into the intestine (Nelms
364-365). Gastric bypass surgery is not recommend for the pediatric population
because there are multiple unknown factors in general. It can be a controversial
topic because children are still growing and developing. Performing such a major
surgery with significant changes to their bodies can be dangerous. As with diet
aids, I would recommend to her parents that establishing a healthy lifestyle should
be done first. I would provide Missy and her family with nutrition education. This
way she will learn proper eating habits at a young age and then can continue it
into adulthood. Before making any major decisions such as surgery, it is
important to incorporate healthy lifestyle changes first. It is considered as a last
resort with changes in diet and physical activity being the most successful and
healthiest way to treat childhood obesity.
VI.
Nutrition Monitoring and Evaluation
24. When should the next counseling session with Missy be scheduled?
Missy’s next counseling session should be scheduled within 2 weeks after the
initial session. This will give the family time to adjust to the new changes in diet
and physical activity. It will also allow time for the changes to take effect on
Missy. Another reason for the scheduled time is to be able to closely monitor and
evaluate Missy.
25. Should her parents be included? Why or why not?
Missy’s parents should be included in the counseling session due to her young
age. As indicated in her medical record, she is dependent on her parents who do
the household’s food shopping and preparation. Her parents also need to be
educated on healthy food choices in order to facilitate successful changes in
Missy’s diet and overall lifestyle. Missy will also need encouragement along the
way from her family and if her parents know exactly what is going on in her
sessions and how to properly handle the situations, it will ensure a more
successful outcome.
26. What would you assess during this follow-up counseling session?
During the follow-up counseling session, I would want to assess Missy’s sleep
apnea. This would be important to cover due to the fact that it was the initial
reason for her visit to her pediatrician. Asking her parents about her sleep
patterns, if any issues are occurring, and if improves are being made. Along with
sleep apnea, I would assess her diet and her physical activity level. I would
perform a diet recall and also check her diet and physical activity log to check for
improvements in areas such a lowering her fat intake and increasing her daily
activity. Performing a physical exam to assess for weight loss and any other
changes would occur. I would want to check her cholesterol levels as well.
Finally, I would answer any questions that Missy and her family might have about
their plan and establish new or diet goals if needed.