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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.