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Zach Pfirrman 10/8/13 KNH 411 Pediatric Weight Management Understanding the Disease and Pathophysiology 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. 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, and the body’s efficiency at storing energy. Each person’s body may have a genetically determined metabolic “set point. It has been researched that people below the poverty line are more likely to be overweight. This may be due living in a “toxic food environment”, meaning they are surrounded by the convenient availability of low-cost, tasty, energy-dense foods, in large portion sizes. We now live in the fast-food era so we end up eating out much more often. If one is engaging in a sedentary lifestyle the risk of being overweight is increased. Physical activity is important to remove or burn off excess calories in one’s body. Nutrition Therapy & Pathophysiology p.257-258 2. Describe health consequences of overweight and obesity for children. Children who are overweight or obese are at higher risk of developing health problems such as heart disease, Type II diabetes, asthma, sleep apnea, and social discrimination. http://www.letsmove.gov/health-problems-and-childhood-obesity 3. Jamey has been diagnosed with obstructive sleep apnea. Define sleep apnea. Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound. http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/ 4. Explain the relationship between sleep apnea and obesity. Sleep apnea is said to be caused when the breathing passage can narrow so much that no air can get through and the patient stops breathing. This can be increased in patients who are overweight. 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. http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Sleep_apnoea Understanding the Nutrition Therapy 5. What are the goals for weight loss in the pediatric population? Goals for weight loss for the pediatric population would include reducing the amounts of fat consumed by children to a normal range, eating nutrient dense foods, mainly fruits and vegetables, and finally ensuring that children get in a fair amount of exercise to avoid a sedentary lifestyle. 6. Under what circumstances might weight loss in overweight children not be appropriate? Weight loss would not be appropriate in children who are just barely overweight because they are at that point right before puberty when it is normal for children to put on a little weight before they grow taller and slim down. Weight loss in children should only be done when the kids are in the obese percentile. 7. What would you recommend as the current focus for nutritional treatment of Jamey's obesity? The current focus nutritionally for Jamey's obesity would be to reduce her fat intake to a level suitable for a female at her age. We would also need to focus on reducing her calories as a whole and replacing a lot of the processed foods with fresh fruits, vegetables, and whole grains. Nutrition Assessment 8. Evaluate Jamey's weight using the CDC growth charts provided. 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. Jamey's BMI is 24.9, which puts her in the 97th percentile for females her age. Anything above the 95th percentile is classified with a weight status of Obese. Based upon Jamey's height and age, her optimal weight should be between 65 lb-92 lb. That would put her in the BMI percentile range of 5-85 with is the healthy range. Medical Nutrition Therapy: A Case Study Approach p.8 9. Identify two methods for determining Jamey's energy requirements other than indirect calorimetry, and then use them to calculate Jamey's energy requirements. I decided to use the Mifflin-St. Jeor Method and the Harris Benedict Method to calculate Jamey's energy requirements. Mifflin-St. Joer: 10 x 52.2kg + 6.25 x 144.8cm – 5 x 10y/o – 161 = 1216 Harris Benedict: 655 + (9.56 x 52.2kg) + (1.85 x 144.8cm) – (4.68 x 10) = 1375 I multiplied these answers by a PAL of 1.4 for her very low activity level. This puts the numbers at 1702 and 1925. Nutrition Therapy & Pathophysiology p.241-242 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. The foods and beverages that fit the high fat content criteria are bologna and cheese sandwich, mayo, Twinkies, Frito chips, fried chicken, and fried okra. The calorie-dense beverages that Jamey consumes are Whole milk, Sweet tea, and Coca-Cola. Medical Nutrition Therapy: A Case Study Approach p.5 11. Calculate the percent of kcal from each macronutrient and the percent of kcal provided by fluids for Jamey's 24-hour recall. I entered Jamey's 24 hour recall into fitday.com to find the amount of grams of each macronutrient and the total calories consumed. Total kcal was 3809 and this consisted of 160.7g FAT, 452g CHO, and 146.9g PRO. Of the calories consumed, 894kcal came from fluids. Fat- 160.7 x 9 = 1446.3kcal / 3809 = 0.3797 x 100 = 38% Protein- 146.9 x 4 = 587.6kcal / 3809 = 0.1542 x 100 = 15% Carbohydrate- 452 x 4 = 1808 / 3809 = 0.4746 x 100 = 47% Fluids- 894kcal / 3809 = 0.2349 x 100 = 23% http://www.fitday.com/ 12.Increased fruit and vegetable intake is associated with decreased risk of overweight. What foods in Jamey's fall into these categories? Really the only foods that can truly fall into this category is the apple juice. Other than that only the fried okra and jelly come even remotely close to servings of fruits and vegetables. This is going to be one of the biggest reforms that needs to take place in her diet. Medical Nutrition Therapy: A Case Study Approach p.5 13. Use the ChooseMyPlate online tool to generate a customized daily food plan. Using this eating pattern, plan a 1-day menu for Jamey. Breakfast Egg White Omelet Turkey Bacon Whole Wheat Toast w/ Jelly Apple Slices Orange Juice Lunch Turkey on Whole Grain Bread w/ cheese and lite Miracle Whip Banana Baby carrots and Peanut butter Fat free Vanilla Yogurt Apple Juice Snack Orange Slices Water Dinner Marinated Chicken Breast Green beans Seasoned Red Potatoes Dessert Fat Free Frozen Yogurt 14. Now enter and assess the 1-day menu you planned for Jamey using the MyPlate SuperTracker online tool. Does your menu meet macro- and micronutrient recommendations for Jamey? When my 1-day menu was put into Fitday.com and was assessed, the macronutrient percentages were as followed: Carbohydrates- 55%, Protein- 22%, and Fat- 23%. The carbohydrate percentage is spot on while the percentage of fat and protein are a little off. I would like to decrease protein a small amount. These percentages are not bad in any sense. As far as micronutrients, I need to increase the amount of iron and vitamin D in the menu. Otherwise the menu meets that recommended amounts of micronutrients. http://www.fitday.com/ 15. Why did Dr. Lambert order a lipid profile and blood glucose test? What lipid and glucose levels are considered altered for the pediatric population? Evaluate Jamey's lab results. Dr. Lambert ordered the lipid profile test to assess her total cholesterol, HDL, LDL, and triglyceride levels. High LDL and lipid levels contribute to adverse affects to ones health. The blood glucose test measures the amount of sugar called glucose in a sample of Jamey’s blood. Dr. Lambert ordered the test to check for diabetes since Jamey has a family history of it and signs connected to the disease. Her mother and grandmother experienced gestational diabetes. Abnormal levels of lipids for pediatrics are an amount greater than 140mg/dL. Abnormal glucose levels would be anything above 110 mg/dL She is low in her HDL levels and just barely within the healthy LDL range. Her glucose level is on the high side as well. Medical Nutrition Therapy: A Case Study Approach p.6 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? There is a lot of processed foods and which tend to have higher fat and sodium content. Another behavior would be the fact that Jamey eats multiple snacks between her major meals which is a concern for her diet. The large portions play a critical role in Jamey's diet, which may be caused by her parents’ inability to control her consumption. Aspects of Jamey's life that place her at an increased risk for overweight include: her appetite with a wide variety of food, her low physical activity level, and hobby of playing video games and reading. 17. You talk to 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? Snacks in between meals are an ok thing to have, given that the snacks are healthy. This would include fruits, vegetables, and maybe some whole grains. This could in fact help her by decreasing the size of her major meals by including small snacks between. Desserts should never be given as a reward for exercise. One, it is not a good fuel for the body and two, it will put the idea in her head to always eat bad foods after exercise. 18. Identify one specific physical activity recommendations for Jamey. Even though Jamey's school no longer has a physical education program, I would see if they had any sports teams that Jamey might want to participate in. If the school did not, I sure there are city leagues and sports clubs she could join. Nutrition Diagnosis 19. Select two nutrition problems and complete PES statements for each. 1) Excessive fat intake (NI-5.6.2) related to lack of knowledge of fat content in foods eaten on a regular basis as evidenced by Jamey's 24 hour recall. 2) Physical inactivity (NB-2.1) related to school physical education program suspended as evidenced by personal statement that her physical activity level is generally low. Medical Nutrition Therapy: A Case Study Approach p.5 Nutrition Intervention 20. For each PES statement written, establish an ideal goal and an appropriate intervention. 1) The goal for Jamey would be to keep her fat intake at 25% of her total kcal. This should be done by removing foods high is saturated fat and foods that are processed. Incorporating vegetables and fruits into her diet along with whole grains will hopefully cause her to eat less fat. 2) The goal for Jamey would be to get in at least 30 minutes of exercise a day. I know that her school no longer has a physical education class but it may have after school sports programs. If it does not then she should look for community or club sports teams to participate in. 21. Mr. and Mrs. Whitmer ask about using over-the-counter diet aids, specifically Alli. What would you tell them? I would not recommend she use over-the-counter diet aids. This would cause her to be reliant on diet pills over the consumption of healthy foods. The best and healthiest way for Jamey to lose weight and get healthy is to eat a better diet and become more physically active. This will bring the best and most long lasting results. 22. Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey. Using EAL, what are recommendations regarding gastric bypass surgery for the pediatric population? It is a controversial topic and often depends on the severity of the obesity of the patient, and the individual patient themselves. I would not recommend this surgery for Jamey because she is at the age where her body is about to or already is going through puberty. At this this in her life it would be more wise to change her diet and lifestyle over having her go through an intense procedure in hopes of weight loss. Nutrition Monitoring and Evaluation 23. What is the optimal length of weight management therapy for Jamey? We would try to go as long as needed to get Jamey into the healthy BMI percentile for her age. We would do this by trying to lose 2 pounds a week for the first six months and then 1-2 pounds a week from then on. Nutrition Therapy & Pathophysiology p.264 24. Should her parents be included? Why or why not? Yes. Jamey’s parents should be included because she is at that age where she is largely dependent on her parents. Jamey's parents are also probably not knowledgeable about what foods are good for them and how a proper diet should be. If Jamey is going to make successful changes in her lifestyle, her parents need to be encouraging and be educated on the positive lifestyle and nutrition choices that will allow Jamey to succeed. 25. What would you assess during this follow-up counseling session? I would start out asking if her sleep apnea is still occurring. Then I would assess the food journal I would have had her do to see if there is a positive change to the diet we came up with. I would also assess if there is an improvement in her physical activity level. Work Cited FitDay - Free Weight Loss and Diet Journal. (n.d.). FitDay - Free Weight Loss and Diet Journal. Retrieved October 15, 2013, from http://www.fitday.com/ Health Problems and Childhood Obesity | Let's Move!. (n.d.). Let's Move!. Retrieved October 13, 2013, from http://www.letsmove.gov/health-problems-and-childhood-obesity Nelms, M. (2013). Medical nutrition therapy: a case study approach (4th ed.). Stamford, Connecticut: Cengage Learning. Nelms, M. N. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning. Sleep apnoea | Better Health Channel. (n.d.). Home | Better Health Channel. Retrieved October 9, 2013, from http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Sleep_apnoea What Is Sleep Apnea? - NHLBI, NIH. (n.d.). NIH Heart, Lung and Blood Institute. Retrieved October 8, 2013, from http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/