Download Answer Guide for Medical Nutrition Therapy: A Case Study

1
Pediatric Weight Management
Case Questions
Submitted by
Michaela M. Phillips
In fulfillment of partial requirements of NUTR 504
Professor Eileen Fitzpatrick
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Sage NCP Form
Student Name: Michaela M. Phillips
Case: #1, Pediatric Weight Management
Patient: Jamey
Referred for: Nutrition Counseling for weight management
NUTRITION ASSESSMENT
Food and Nutrition Related History: Low physical activity level (FH-7.3); 24hr recall indicates high consumption of sugar added beverages and
high carbohydrate-high fat snacks. Actual calorie intake (4493) exceeded recommended intake using Diet Analysis Plus (1726) by 2767 calories.
Anthropometric Measurements
Age: 10
Gender
Ht:
Female
57 in
Biomedical Data, Medical Tests & Procedures
Labs/Date
Albumin Glucose HbA1C
BUN
11/20
108
5.5 %
mg/dL
Wt: 115 lbs
Wt Hx: Overweight since birth
Creat
Na+
K+
BMI:
24.88; above 97th percentile; obese
Hgb
LDL
110
mg/dL
TG
114
mg/dL
HDL-C
50
mg/dL
(low)
Medical Diagnosis/Relevant Conditions: Obstructive Sleep Apnea secondary to obesity and physical inactivity.
Pertinent Medications/Supplements/Herbs:
Flintstones vitamin daily.
Skin status:
□ Intact □ Pressure Ulcer/Non-healing wound; Comments: Warm, dry skin with slight rash in skin folds.
Patient/Client/Family Medical/Health/CAM History: Mother and grandmother had possible gestational diabetes and type 2 Diabetes Mellitus.
Estimated Nutritional Needs Based on Comparative Standards:
Calories
Protein
Fluid
1789.5 Kcal per day for weight maintenance
(REE calculated using Mifflin-St. Jeor = 1383 Kcal x
1 (sedentary))
(TEE calculated using IOM DRI for overweight girls
= 1789 Kcal)
Current Diet Order
None
.95 g/Kg or 50 g per day
1.8 L (1 mL per Kcal)
Feeding Ability
x Independent
Oral Problems
□ Chewing Problem
Intake
x Good (> 75%)
□
□
□
□
x
□
□
□
Limited Assistance
Extensive/Total Assistance
Swallowing Problem
Mouth Pain
None of the Above
□ No Nutritional Diagnosis at this time
NUTRITION DIAGNOSIS
x
P (problem): NI-1.5 Excessive Energy Intake
related to:
E (Etiology): Lack of understanding of energy
intake requirements. as evidenced by:
P (problem): NB-1.1 Food and Nutrition
related knowledge deficit related to:
E (Etiology): Lack of prior exposure to
accurate nutrition-related information as
evidenced by:
Fair (approx. 50%)
Poor (<50%)
Minimal – (<25%)
Proceed to Nutrition Diagnosis Below
S (Signs & Symptoms): BMI of 24.88, which
is above 97th percentile; HbA1C of 5.5%; HDL
50 mg/dL.
S (Signs & Symptoms): Excessive intake of
energy.
INTERVENTION
Recommended Nutrition Prescription:
Adjust diet to 2000 calories per day and maintain nutrient density; increase aerobic physical activity to 30 minutes per day pending physician
approval.
Food or Nutrient Delivery:
Nutrition education:
ND-1.1; ND-1.2; ND-1.3; Meals and snacks
Portion sizes; sugary and high fat foods to avoid; MyPlate for kids;
MyActivity Pyramid for kids; healthy snack options for kids
Nutrition Counseling: C-2.2; goal setting
Coordination of Care (refer to): Physician for determination of physical
activity.
Goal(s): Weight loss of 1 lb per month; reduce empty calories by 50%, high sugar and high fat foods in the diet; reduce sugar sweetened beverages
by 50%; switch to healthy lower calorie snack options.
MONITORING & EVALUATION
Indicators:
BMI
Criteria:
19 or less than 85th percentile.
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HbA1C
HDL
1.
Equal or less than 5.2
Greater than 55
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.
a. Genetics: Genetics determines the ability to detect hunger and satiety cues. If a child has an imbalance in hunger
hormones or chemical messengers that indicate satiety, then there is a likelihood the child could overeat and become
overweight or obese. Parental obesity means there is a higher likelihood a child will be obese. Prader-Willi syndrome is
rare but causes obesity.
b. Environment: Environment influences how food habits develop. Children tend to imitate parents and adopt their likes
and dislikes. The TV can also influence food choices generally toward sugary and fatty foods. Positive family meals
enhance the ability to make nutritious choices and decrease the likelihood of drinking sugar sweetened beverages. These
meal times allow enough time to enjoy the food and people. Occasional spills are tolerated and the entire family
participates in conversation. School meals should allow enough time to enjoy the food and provide healthy and
nutritious options. A poor environment where meals are rushed, not all are included in conversation, and negativity
prevails can lead to poor nutrition and poor performance.
c. Nutritional intake: If a child takes in foods or beverages that are high in added sugars and fats that are calorie dense,
they are likely to take in too many calories and not get enough nutrients in their diets. The parents are responsible for
presenting nutritious selections at meal and snack times and the child decides how much to eat. If nutritious food is
offered, the child is likely to take in the recommended amount of nutrients. If non-nutritious options are offered, the
child may over consume and displace healthier options.
2.
Describe health consequences of overweight and obesity for children. The earlier a child becomes overweight or obese,
the more likely they are to be overweight or obese in adulthood. Being overweight and obese can lead to development of
chronic diseases such as type II diabetes mellitus, cardiovascular disease, heart disease, cancer, and atherosclerosis.
Being overweight or obese requires more energy to move and many who are overweight or obese are discouraged from
exercising due to the extreme effort it requires to move the excess mass. Being overweight can lead to psychosocial
issues in relationships at school, church, or with siblings.
3.
Jamey has been diagnosed with obstructive sleep apnea. Define sleep apnea. Sleep apnea is a disease where a person
stops breathing for a period of time due to obstruction of the airway.
4.
Explain the relationship between sleep apnea and obesity. Obesity causes an excess of mostly adipose tissue to
accumulate throughout the body. When sleeping, muscles relax and the excess tissues especially in the neck and face
can actually block air during inspiration and stop a person from breathing until the muscles kick in and force the
breathing to begin again. When this happens multiple times and for longer durations each time, the person is diagnosed
with sleep apnea. So the excess tissue from the obesity causes the obstruction that leads to sleep apnea.
5.
What are the goals for weight loss in the pediatric population?
BMI Percentile
Age
85TH-94TH
No risks
2-5
6-11
12-18
Maintain weight velocity
95th-98th
>=99th
With risks
Decrease weight
velocity or weight
maintenance.
Weight maintenance
Gradual weight loss of
up to 1lb/mo if BMI is
very high (>21 or 22
kg/m2)
Decrease weight
velocity or weight
maintenance.
Weight maintenance
or gradual loss
(1lb/mo)
Weight loss not to
exceed an average of 2
lb/wk
Weight loss not to
exceed an average of
2 lb/wk
Weight loss not to
exceed an average of 2
lb/wk
Maintain weight velocity
Maintain weight velocity.
After linear growth
Decrease weight
complete, maintain
velocity or weight
weight
maintenance.
Pediatrics December 2007 vol. 120 no. Supplement 4 S164-S192 doi: 10.1542/peds.2007-2329
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distributed with a certain product or service or otherwise on a password-protected website for classroom use.
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6.
Under what circumstances might weight loss in overweight children not be appropriate? Weight loss would not be
appropriate for children who are less than the 95 th percentile for BMI. It would not be appropriate in certain disease
cases or if someone is pregnant.
7.
What would you recommend as the current focus for nutritional treatment of Jamey’s obesity? She should initiate
gradual weight loss of 1lb per month and focus on reducing empty calories in her diet; she should replace unhealthy
snacks with healthier snack options.
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. Her BMI
percentile is 97% and she is obese. Optimal weight for her age is about 75lbs.
9.
Two methods for determining Jamey’s energy requirements other than indirect calorimetry:
Mifflin St. Jeor REE: 10(wt = 52.3Kg) + 6.25 (ht = 144.78 cm) – 5 (age=10) + 5 = 1382.9 Kcals (PA level of 1
time 1382.9 = 1382.9 Kcals)
Institute of Medicine equation for weight maintenance in overweight girls:
TEE = 389 – (41.2 × age [y]) + PA × (15.0 × weight [kg] + 701.6 × height [m])
389-(41.2 * 10) + 1* (15.0 * 52.3 + 701.6 * 1.45) = 1789 kcals
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: Sugar in coffee, Frito corn chips; Mayonnaise
on the sandwich; Twinkies; Fried chicken; butter in mashed potatoes; fried okra; sweet tea; coca cola; and possibly the
popcorn if it is buttered.
11. Percent of kcal from each macronutrient and the percent of kcal provided by fluids for Jamey’s 24-hour recall.
Item Name
Milk, Whole 3.3%
Juice, Apple, Unsweetened, Canned
Coffee, Brewed
Cream, Half and Half
COCA-COLA Coke Soda
Milk, Whole 3.3%
Kcal(kcal)
148.84
57.04
1.7775
78.65
210
148.84
NESTEA Iced Tea Drink, Sweetened
Milk, Whole 3.3%
157.5
223.26
1025.91
% total cal
23%
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distributed with a certain product or service or otherwise on a password-protected website for classroom use.
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12. Increased fruit and vegetable intake is associated with decreased risk of overweight. What foods in Jamey’s diet fall into
these categories? Just the 4oz apple juice, 2 tbsp grape jelly, and 1 c. fried okra.
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. There is a risk that she could
have metabolic syndrome or diabetes. The low HDL of 50 mg/dL (ref: >50) could be raised by incorporating physical
activity daily.
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?
Factors that place people at risk of being overweight are genetic, environmental and diet based. The fact that she
has a sedentary lifestyle and that she has a poor diet are two major factors in Jamey’s obesity. The fact that the school
budget cut physical activities out is another big environmental factor. Family meals and physical activity are two major
aspects of Jamey’s life that place her at increased risk for being overweight.
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?
Generally, studies have shown that rewarding with dessert tends to override hunger/satiety cues and promotes overeating
to get the reward.
18. Identify one specific physical activity recommendation for Jamey. I would recommend 30 minutes of exercise per day
such as brisk walking as long as a physician has permitted it.
19. Select two nutrition problems and complete PES statements for each.
P (problem): NI-1.5 Excessive Energy Intake
related to:
E (Etiology): Lack of understanding of energy
intake requirements. as evidenced by:
P (problem): NB-1.1 Food and Nutrition
related knowledge deficit related to:
E (Etiology): Lack of prior exposure to
accurate nutrition-related information as
evidenced by:
S (Signs & Symptoms): BMI of 24.88, which
is above 97th percentile; HbA1C of 5.5%; HDL
50 mg/dL.
S (Signs & Symptoms): Excessive intake of
energy. Calories exceed requirements by 2700
Kcals.
20. For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention
(based on etiology).
For problem NI-1.5, the recommendation would be to adjust the diet to 2000 calories per day and maintain nutrient density; increase
aerobic physical activity to 30 minutes per day pending physician approval.
ND-1.1; ND-1.2; ND-1.3; Meals and snacks
Weight loss of 1 lb per month; In 4-6 weeks, a loss of 4-6 lbs until BMI at or below the 85th percentile is achieved.
Reduce empty calories, high sugar and high fat foods in the diet; limit fried foods to 8oz per week and select other cooking methods
the rest of the week.
Reduce sugar sweetened beverages to one per day; have 4oz juice per day.
Switch to healthy lower calorie snack options. Consider raw fruits or vegetables with low calorie dips.
Switch to reduced fat or skim milk instead of whole milk.
For problem NB-1.1, the instruction would happen on the spot because studies have shown that, if clients are handed
information and it is not discussed, the likelihood of them reading it is not very high.
21. Mr. and Mrs. Whitmer ask about using over-the-counter diet aids, specifically Alli (orlistat). What would you tell them?
This drug is not approved for children less than 12 years old (PEDIATRICS Volume 120, Supplement 4, December 2007, pg. S277,
downloaded from pediatrics.aappublications.org by guest on March 9, 2014).
22. Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey. Using the EAL, what are the recommendations
regarding gastric bypass surgery for the pediatric population?
BMI of 40 kg/m 2 with a medical condition or 50 kg/m2; physical maturity (generally 13 years of age for girls and
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15 years of age for boys) (PEDIATRICS Volume 120, Supplement 4, December 2007 pg S185, retrieved March 9, 2014
from pediatrics.aappublications.org on March 9, 2014).
23. What is the optimal length of weight management therapy for Jamey? It is at least 3 months per the EAL. The length of
therapy depends on many factors including maintaining the diet plan and whether or not she has any growth. Because
her ideal weight for her age and stature is around 75 pounds, it could take over a year for her weight to come down and
her to grow into an ideal weight.
24. Should her parents be included? Why or why not? The parents should definitely be included because they have a major
role in her nutrition. If they model appropriate nutrition, it will make it easier for Jamey to stick to her plan. The parents
are responsible for offering healthy options and Jamey is responsible to choose how much to eat.
25. What would you assess during this follow-up counseling session? Food intake, physical activity records, BMI and
weight would be reassessed during the follow up session to see if any progress was made or determine the reasons why
progress was not made and see if there are any other courses of action for Jamey and her parents. If there are any gaps in
understanding directions, more information would be given out.
© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license
distributed with a certain product or service or otherwise on a password-protected website for classroom use.