Download File - Clinical Nutrition Manual Mariah Guthrie

Weight Management Case Study 1
Weight Management Case Study
Mariah Guthrie
Miami University
Weight Management Case Study 2
I. 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.
Genetic, environment and nutritional intake factors all play a very large role in
developing obesity. Body frame can be a factor in obesity and it can also play a
role on how easy it is to maintain a healthy weight. For those built with a small
frame it is easier to keep weight off and sometimes burn off weight once it is
gained. Environment and nutritional intake play a bigger role because they can be
adjusted. Environmental factors would include your daily life, physical activity
and type of job. Some jobs are desk jobs and encourage workers to stay seated,
this can cause someone with an active lifestyle to move less frequently because of
the demands of their job. Environmental factors also include what kinds of foods
you have access to or what kind of foods someone can afford. Healthy foods tend
to be higher priced and not everyone can afford them. Higher quality foods tend
to be lower in fat as well. Nutritional intake is also a big factor foods high in
simple carbohydrates, fat, cholesterol, salt and sugar are all readily available and
very cheep. For those looking to shop on a budget these foods are the best deal
unfortunately all these foods are also prone to aiding in the development of
obesity and other medical conditions (usually related to weight) (Obesity: Genetic
or Environmental).
2. Describe the health consequences of overweight and obesity for children.
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Childhood obesity has long-term effects as well as short term effects. Children
who are overweight or obese are at an increased risk for: cardiovascular disease,
high cholesterol, high blood pressure, prediabetes, sleep apnea and bone and joint
problems. Long term effects of children who are overweight include: cancer, type
2 diabetes, stroke, osteoarthritis and they will also more likely be overweight
adults (Childhood Obesity Facts).
3. Jamey has been diagnosed with obstructive sleep apnea. Define sleep apnea.
Sleep Apnea is a common chronic condition that causes breathing to pause or
become very faint while sleeping. The pause in breathing can last for seconds to a
couple minutes. Because of the breathing patterns of those who suffer from sleep
apnea sleeping is not restful and often leaves the sufferer to be constantly tired
(NIH).
4. Explain the relationship between sleep apnea and obesity.
Obesity is a common risk factor for sleep apnea. This is because extra fat tissue
can line the windpipe and make it harder for it to stay open while sleeping (NIH).
II. Understanding the Nutrition Therapy
5. What are the goals for weight loss in the pediatric population?
For children weight loss goals include increase in activity. For children who are
under 10 years old it is not recommended that they loose weight unless they are
severely overweight. For kids over the age of 10 years old it is important to make
sure they are getting enough exercise and slowly changing their diet so they do
not loose weight too quickly as this can effect their growth (Griffin).
6. Under what circumstances might weight loss in overweight children not be
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appropriate?
Children who are very young (under the age of 7) should not be recommended for
weight loss because they are still growing and developing. Children who have
medical conditions that cause them to gain weight or those who are recovering
from an injury should not be recommended for weight loss either, loosing weight
at the current time will stress their systems more than they already are (Griffin).
7. What would you recommend as the current focus for nutritional treatment of Jamey’s
obesity?
By looking at Jamey’s lab results and her 24-hour recall it is apparent that
changes need to be made to her diet and her physical activity. She consumes a
large amount of high fat foods and large quantities of surgery drinks. Her lab
results showed that her HDL cholesterol is low, her LDL/HDL ratio is high and
her overall cholesterol is on the high end. It is important to educate her on the
importance of consuming lower fat foods, vegetables, fruits and lower fat milk. It
is also important to teach her enjoyable ways to get more physical activity.
III. Nutrition Assessment
8. Evaluate Jamey’s weight using the CDC growth charts provided (p.8): 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.
Based on Jamey’s height and weight for age she falls into the 97th percentile, she
is considered obese. The average child her age and height should weight between
70 and 75 lbs. Jamey is 40 lbs. overweight.
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9. Identify two methods for determining Jamey’s energy requirements other than indirect
calorimetric, and then use them to calculate Jamey’s energy requirements.
EER females 9-18 years: EER= 135.3 - 30.8 x age + PA x (10.0 x weight (kg) +
934 x height(m)) + 25
Height=57”, 1.447m
Weight=115lbs., 52.27 kg
PA= 1.16 low active
135.3 - 30.8 x 10 + 1.16 x (10 x 52.27 + 934 x 1.447) + 25=EER
EER=2,026.4
TEE for overweight females: TEE= 389 – 41.2 x age + PA x 15.0 x weight +
701.6 x height
PA=1.18 low active
389 -41.2 x 10 + 1.18 x (15 x 52.27 + 701.6 x 1.447)=TEE
TEE=2,100
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.
By viewing Jamey’s 24-hour recall it is clear that the majority of the beverages
and other foods that she consumes are high in fat or added sugar these foods
include: breakfast burritos, whole milk, bologna, cheese mayo, chips, twinkies,
fried chicken, fried okra, sweet tea and soda.
11. Calculate the percent of kcal from each macronutrient and the percent of kcal
provided by fluids for Jamey’s 24-hour recall.
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Values found on FitDay.com
Food
Kcal
Carbs(g)
Fat (g)
Protein (g)
Breakfast
2
burrito, ham
and cheese
Whole Milk 3 cups (24 fl
oz)
Apple Juice 4 fl oz
423.7
55.6
13.86
19.21
446.5
35.1
23.79
23.06
57
14
0.16
0.12
Coffee
6 fl oz
2
0
0.1
0.2
Cream
¼ cup
78
2.6
6.9
1.78
Sugar
2 tsp
33
8.4
0
0
Bologna
2 slices
174.6
3.1
13.94
8.62
Cheese
2 slices
162.7
1.8
12.43
10.8
White bread
6 slices
382
70.6
4.59
13.18
Mayo
2 Tbsp
198
1.1
21.6
0.3
Fritos
1 oz
139
18.3
6.1
2.5
Twinkie
2 cakes
300
54
9
2
Peanut
butter
Jelly
2 Tbsp
188
6.3
16.12
8.03
2 Tbsp
101
26.6
0
0
Fried
Chicken
3 pieces(two
legs one
breast)
1 cup
642
19.1
39.08
53.47
276
36.8
12.7
4.1
1 cup
173
13.1
12.9
2.4
3 cups
190
20.9
10.9
3.58
Mashed
potatoes
with whole
milk and
butter
Fried Okra
Buttered
popcorn
Amount
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Coca-cola
12 oz
137
35.3
0.1
0.3
Total
-
4,103.5
422.7
41%
204.27
44%
153.65
14%
12. Increased fruit and vegetable intake is associated with decreased risk of
overweight. What foods in Jamey’s diet fall into these categories?
According to her 24-hour recall apple juice, mashed potatoes and okra are the
only foods that could be considered fruits or vegetables. Unfortunately most of
these have added fats. The mashed potatoes had whole milk and butter added to it,
the okra was fried and we are unsure weather or not the apple juice was 100%
apple juice. Due to the fact that all of her vegetable or fruit servings either have
added fat or added sugar they are not attributed to weight loss or being quality
servings of fruits or vegetables.
13. Use the ChooseMyPlate online tool to generate a customized daily food plan.
Using this eating pattern, plan a 1-day menu for Jamey.
Based on the servings allowed on the MyPlate meal plan the following is a 1 day
sample menu.
Meal
Breakfast
Snack
Lunch
Snack
Dinner
Food
1 cup skim milk, ½ cup cut up bananas,
1 cup whole grain cheerios
1 cup baby carrots, 1 banana
2 slices whole wheat bread, 3 oz turkey,
1 oz low fat cheese, 1 tbsp mayo, ½ cup
green beans, ½ cup grapes, 1 cup skim
milk
½ cup spinach, ¼ cup diced tomatoes, 1
tbs ranch dressing
3 oz grilled chicken, 1 cup brown rice,
½ cup steamed broccoli, ½ cup steamed
carrots, 1 cup skim milk
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1 Medium apple, 4-5 crackers, 1 tsp
peanut butter
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?
Based on a 2,000 kcal diet she will get enough of every macronutrient and is close
to the target. Potassium and Iron were low however they did not have a fortified
whole grain cereal option available. The sample meal plan was also low on
vitamin D as well but the database did not have a skim milk that was fortified
with calcium and vitamin D. All of the items that were highlighted as being under
the recommended daily allowance were very close to the recommended value.
15. Why did Dr. Lambert order a lipid profile and blood glucose tests? What lipid and
glucose levels are considered altered (i.e., outside of normal limits) for the
pediatric population? Evaluate Jamey’s lab results.
Dr. Lambert ordered a lipid profile in order to assess fat metabolism. A lipid
profile tracks cholesterol in the blood normal levels each are listed: total
cholesterol 170 mg/dL, LDL, <110 mg/dL, HDL, >55 mg/d (Nelms & Roth,
2014). He ordered the glucose test to note blood glucose levels. Blood glucose
levels can indicate hyperglycemia, hypoglycemia and is used to diagnose
diabetes. Blood glucose tests are very important for patients like Jamey because
obesity is a risk factor of diabetes and a blood glucose test is one of the few ways
to diagnose it. Normal levels for blood glucose lies between 70 and 110 mg/dL
Weight Management Case Study 9
(Glucose, 2014).
16. What behaviors associated with increased risk of overweight would you look for
when assessing Jamey and her family’s diets? What aspects of Jamey’s lifestyle
place her at increased risk for overweight?
Her families diets are very high in fats. An easy way to lower overall fat
consumption is by cooking foods in healthier fats or not adding extra fat to foods,
this includes grilled chicken instead of fried, skim milk instead of whole and not
adding butter, cream or whole milk to foods when cooking. She also leads a
sedentary lifestyle and gets little to no exercise.
17. You talk with 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?
Using food as a reward is never a good idea. Rewarding kids with junk food
encourages poor eating habits and goes against healthy eating habits. Supplying
kids with food high in sugar, fat and salt only makes them crave these foods even
more and can cause overeating. It also encourages kids to eat when they are not
hungry but because they “deserve a reward”. Instead of rewarding a child with
food they should be rewarded by being allowed to do something like: 10 more
minutes of play time or 10 more minutes of reading time (Why parents Shouldn’t
use Food as a Reward or Punishment). rri
Eating snacks are not always the best idea, in some cases it can encourage people
to eat even if they are not hungry. However in Jamey’s case he calorie intake is
going to be reduced significantly (from around 4,000 to 2,000 kcal per day)
Weight Management Case Study 10
because of her significant reduction in calories she is gong to be hungry between
meals. It is important for her to snack through out the day to keep her from feeling
hungry. It is also important to make sure that she is snacking on healthy snacks
that are low in fat. Eating smaller meals and keeping from being hungry keeps her
from eating an excessive amount of calories later on in the day (Myth or Fact:
Many Meals Thorough out the Day are Better than just Three).
18. Identify one specific physical activity recommendation for Jamey.
Jamey is not currently getting any physical activity at all. She could start with 1530 minute walks everyday when she gets home from school. She can also get in
exercise from riding her bike to school, taking a family pet for a walk or playing
outside with friends.
IV. Nutrition Diagnosis
19. Select two nutrition problems and complete PES statements for each.
1. Excessive energy intake related to an energy intake higher than her
recommended energy needs do to lack of education as evidence by her 24-hour
recall and being in the 95th percentile for her age based on weight and height.
2. Lack of physical activity related to a lack of interest or encouragement as
evidence by her interest in sedentary activities and being in the 95th percentile for
her age based on weight and height.
V. Nutrition Intervention
20. For each PES statement written, establish an ideal goal (based on signs and
symptoms) and an appropriate intervention (based on etiology).
1. Based on Jamey’s 24-hour recall she is consuming more than double the
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number of calories she needs. She will be put on a 2,000-2,100 kcal diet. The
focus would be to make sure she gets at least 2 ½ cups of vegetables, 2 cups of
fruit and sticks to a low fat low cholesterol diet. Instead of consuming whole milk
she will be switched to skim milk, she will also focus on consuming foods lower
in fats like grilled chicken instead of fried chicken. Her added fat intake will also
be reduced so instead of adding 1 tbsp. butter 1 tsp. of butter will be added.
2. Because Jamey is getting to little to no exercise currently an exercise regimen
will begin with simple exercises and increase in duration and difficulty.
To start she will get 15-30 of low to moderate physical activity 5-7 days per week
by walking the dog, riding her bike to school, playing outside with friends or
playing interactive video games with her family.
21. Mr. and Mrs. Whitmer ask about using over-the-counter diet aids, specifically Alli
(orlistat). What would you tell them?
Orlistat is a lipid inhibitor and can help someone loose weight paired with a
proper diet and exercise however it is not recommended for children under 18, it
has not been research enough on its effects in children. I would not recommend
orlistat for Jamey (Orlistat, 2014).
22. Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey. Using EAL,
what are the recommendations regarding gastric bypass surgery for the pediatric
population?
Gastric bypass surgery has been excessively tested and nearly perfected amongst
the adult population but there has not bee many studies on the long term effects of
a child’s development after the surgery has been preformed. Gastric bypass also
Weight Management Case Study 12
doesn’t guarantee that Jamey will be able to loss all the weight she needs and it
also does not take the place of proper diet and exercise. If a regimen is not
followed all her weight lost can be gained back. Overall it is much safer and
healthier for Jamey to try a diet change and exercise regimen before she
conceders an invasive procedure (Adolescent Bariatric Surgery).
VI. Nutrition Monitoring and Evaluation
23. What is the optimal length of weight management therapy for Jamey?
Ultimately the longer she stays in treatment the more successful she will be (Perri,
1989). However that amount of time spent with one client is not realistic. Weight
loss treatment should last about 3-6 months or until her weight loss goals are met.
She should also be giving plenty of information a guide for a maintenance
program after the 3-6 months (Recommendations Summary).
24. Should her parents be included? Why or why not?
Her parents should be very involved with her treatment since they make most of
the meals she eats teaching them how to cook food in a more healthy can help
Jamey loos weight and keep it off as well as help their whole family become more
healthy as a whole. Also having her parents being directly involved helps them
keep her on track with her diet and exercise plan.
25. What would you assess during this follow-up counseling session?
During a follow up session I would weigh her again to see if she has lost weight
and if she has make sure that she has not lost too much weight too quickly. I will
also have her complete another 24- hour recall to see what she is currently eating
and if it follows her nutrition plan. I will also have her blood work done again in
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order to see her lipid profile to see if her LDL and HDL cholesterol levels are
changing. It is also important to talk to Jamey’s parents to see if she is getting
added exercise after school. From all of these factors I will access weather
changes need to be made to her nutrition intervention plan.
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Works Cited
Adolescent Bariatric Surgery. Cleveland Clinic. Retrieved from
https://weightloss.clevelandclinic.org/bsurgeryadolesandteen.aspx.
Glucose. (2014). Lab Tests Online. Retrieved from
http://labtestsonline.org/understanding/analytes/glucose/tab/test/.
Griffin, Morgan R. Weight loss for Kids. Retrieved from
http://www.webmd.com/parenting/raising-fit-kids/weight/weight-lossrecommendations?page=1.
Myth or Fact: Many Meals Thorough out the Day are Better than just Three. FitDay. Retrieved
from http://www.fitday.com/fitness-articles/nutrition/healthy-eating/myth-or-fact-manymeals-throughout-the-day-are-better-than-just-three.html#b.
Nelms, M., & Roth, S. L. (2013). Medical nutrition therapy: A case study approach.
Stamford, Connecticut: Cengage Learning.
(NIH) National Heart and Lung Association. (2014). Retrieved from
http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/.
Obesity: Genetic or Environmental. (2014). Science Learning. Retrieved from
http://www.sciencelearn.org.nz/Contexts/Uniquely-Me/NZ-Research/Obesity-genetic-orenvironmental.
Orlistat. (2010) Retrieved from http://www.drugs.com/orlistat.html.
Perri, Michael G.; Nezu, Arthur M.; Patti, Eugene T.; McCann, Karen L.
Journal of Consulting and Clinical Psychology, Vol 57(3), Jun 1989, 450-452.
Recommendations Summary. Evidence Analysis Library. Acadamy of Nutrition and Dietetics.
Retrieved from http://www.andeal.org/template.cfm?key=618.
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Why parents Shouldn’t use Food as a Reward or Punishment. (2014) University of Rochester.
Retrieved from
http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=160&Conten
tID=32.