Corinne Smith

October 12, 2015

Case Study
I.
Understanding 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).
The term obesogenic environment refers to those environments that both produce
and promote weight gain and act as barriers to weight loss. Children in these types
of environments struggle against a culture that promotes consumption of energydense foods, high fat, high sugar, as well as sedentary lifestyles. Children can
encounter this at home, in school, and even through the media.
Genetics affect body weight and body composition by influencing such factors as
appetite, taste preference, energy intake, resting energy expenditure, the thermic
affect of food, non-exercise activity thermogenesis, and the bodys efficiency in
storing energy. It is also said that each person has a genetically determined
metabolic set point that maintains body weight within a narrow range.
Understanding the role of genetics is complicated because it does not follow a
strict inheritance manner like other diseases. This means that multiple genes must
be involved, each making a small contribution. Twin and family studies have
proven that 50-60% of BMI is related to genes, but specific genes have not yet
been identified. However, genetics alone does not explain the rapid increase in
obesity. People predisposed to obesity are greatly influenced by lifestyle and
environmental factors, more than those not (Nelms 261-263).
Ones behavior and environment can also greatly impact weigh gain and obesity. A
sedentary lifestyle includes little to no activity and for children will include seated
screen time playing video games or watching television. While watching television
or playing video games children are not burning any calories and may even be
eating while laying around. This will lead to positive energy balance and weight
gain since they are not burning off what they eat. Experimental data has shown
that television watching increases the simultaneous increase of caloric foods.
Caloric intake increased 37% for pizza and 71% for macaroni and cheese during a
30-muinute meal while watching television. A sedentary lifestyle can also lead to

decreased motivation and reversely, a feeling of decreased energy. Other factors

that influence a sedentary lifestyle include the discontinuation of physical
education in schools, lack of safe sidewalks in neighborhoods, increase in
automobile travel, the workplace has become more automated and household
chores are assisted by labor-saving machinery. Socioeconomic status has also been
linked to BMI. Greater access to take out foods was associated with a higher BMI
and increased prevalence of obesity. Take out and fast food options tend to
concentrate in low-socioeconomic neighborhoods and their cheap prices lead to
over consumption. Conversely it has been proven that there is higher fruit and
vegetable consumption in socioeconomically advantaged areas. Changes in the
eating habits of North Americans has also led to increased prevalence of obesity.
Portion sizes are bigger, we eat more often during the day and more calorie dense
foods are being consumed. This changes in diet have to do with the lower cost and
convenience of calorie dense foods. Other environmental influences include growth
of the fast food industry, increased availability of calorie dense foods, increased
number of snack and convenience foods, and a decrease in the proportion of
disposable income parents spend on food.
Society and community promotes and idolizes and ideal body that is close to
impossible to obtain. This pressure on children can lead to eating disorder, lack of
self-esteem, and depression which has been known to increase weight gain. An
individuals relationships can also influence their weight. A child with a poor
parental relationship or a child that has a hard time making friends may turn to
food as a coping mechanism and gain weight without even noticing. Also, obesity
as a child can increase social discrimination. This discrimination can also cause
decreased self-esteem and depression leading to over consumption of foods and
possibly an addiction to food.
(Nelms 262-266)
2. Describe health consequences associated with an overweight
condition. Describe how these -health consequences differ for
overweight versus obese person.
Health consequences associated with overweight and obesity include type 2
diabetes, hypertension, stroke, coronary heart disease, sleep apnea, asthma, liver
and gallbladder disease, osteoporosis, and cancers of the endometrium, breast,
prostate, and colon. Psychosocial and emotional consequences are associated as
well. In North America, them emphasis on the ideal body puts pressure on men,
women, and even children to be thin causing overweight and obese people to

suffer feelings of guilt, depression, anxiety and low self of steam. Overweight and
obesity can also lead to lipid abnormalities, elevated serum triglycerides and
decreased HDL-cholesterol, premature death, the risk of which increased with
weight, increased risk of surgery, and reproductive complications such as
increased risk of fetal and maternal death, gestational diabetes, high birth weights,
increased risk of birth defects, and infertility. Lastly, obesity can also affect the
quality of life through limited mobility a decreased physical endurance as well as
social, academic, and job discrimination (Nelms 260-262). These health
consequences differ for an overweight versus an obese person. With increased
BMI, comes increased risk. Table 12.3 in Nelms classifies overweight as BMI 25.029.9 kg/m2 and obesity as a BMI 30.0- > 40 kg/m2. Overweight BMI as an
increased risk for type 2 diabetes, hypertension, and cardiovascular disease, where
the obese BMIs range from High to extremely high risk. This shows that with the
increase in BMI and waist circumference comes increased risk (Nelms 259).
3. Missy has been diagnosed with obstructive sleep apnea. Define sleep
apnea. Explain the relationship between sleep apnea and obesity.
Sleep apnea is a sleep disorder in which breathing rapidly starts and stops.
Symptoms include snoring loudly and feeling tired even after a full nights sleep.
Obesity may worsen obstructive sleep apnea (OSA) because of fat deposition at
specific sites. Fat deposited in the tissues surrounding the upper airways results in
increased collapsibility of the upper airway, fat deposited around the thorax
reduces chest function and increases oxygen demand, and there is a high
correlation between visceral fat and OSA. However, recent studies show that OSA
may itself cause weight gain due to reduced activity levels and increased appetite
(Romero-Corral 712).
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 basis for treatment in children involves changes in their diet and increased
physical activity. Weight loss is not recommended for babies or young children who
are still growing and developing, the goal would be to maintain weight their weight
while they continue to grow taller. Weight reduction may be recommended for
obese adolescents who have completed their growth or weight more than a
healthy adult. Goals for children older than 7 years of age includes maintaining
baseline weight initially, than adding slow changes in diet and exercise to achieve

weight loss as recommended by their doctor, follow adult guidelines and limit fat
intake, eat a variety of foods that are low in calories, maintain energy balance
(consume enough calories to maintain energy but not more than he/she can burn
off), decrease consumption of high-fat foods, eat more fruits and vegetables, eat
fewer sweets, candies, cookies, chips, and soda, change to skim and low-fat dairy
products, and refer to support groups (Stanford Childrens health). Education on a
healthy diet is might also be a goal, so that when the child grows up and is on their
own, the will know how to maintain a healthy weight. If a serious medical condition
is present and the childs BMI is higher than the 95th percentile, weight loss is
encouraged but only about a pound a month.

5. What would you recommend as the current focus for nutritional

treatment of Missys obesity?
I would focus on nutrition education and an increase in physical activity. I would
educate Missy on healthier options, lower calorie and more nutrient dense foods. I
would recommend she increase her physical activity to at least 30 min a day.
Weightless is not recommend for children who are not yet fully developed, but in
Missys case, since the obstructive sleep apnea is so negatively affecting her daily
life, I would like to see a slow decrease in BMI. I believe this can be accomplished
with changing her diet and increasing physical exercise.
III. Nutrition Assessment
a. Evaluation of Weight/Body Composition
6. Overweight or obesity in adults is defined by BMI. Children ad
adolescents are often times classified as overweight or at risk for
overweight based on 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 pediatric population.
- The CDC uses growth charts that place a childs BMI in a percentile.
Overweight is defined as a BMI at or above the 85th percentile and below the
95th percentile for children and teens of the same age and sex. Obesity is
defined as a BMI at or above the 95th percentile for children and teens of the
same age and sex (CDC). A child's weight status is determined using an ageand sex-specific percentile for BMI rather than the BMI categories used for
adults. This is because children's body composition varies as they age and
varies between boys and girls. Therefore, BMI levels among children and

teens need to be expressed relative to other children of the same age and
sex.

Weight Status Category

Percentile Range
Underweight
Less than the 5th percentile
Normal or Healthy Weight
5th percentile to less than the 85th percentile
Overweight
85th to less than the 95th percentile
Obese
95th percentile or greater
WHO developed the Growth Reference Data for 5-19 years. It is a
reconstruction of the 1977 National Center for Health Statistics (NCHS)/WHO
reference and uses the original NCHS data set supplemented with data from
the WHO child growth standards sample for young children up to age 5. And
Missys gender and age chart is as follows:

(WHO 2014).
- The American Heart Association uses the CDC growth charts to identify
childhood obesity (AHA 2014).
7. Evaluate Missys weight using the CDC growth charts provided. What is
Missys BMI percentile? How would her weight status be classified by
each of the standards you identified in question 6?

According to the CDC growth chart, with a BMI of 25.9 kg/m2, Missy is in the 97th
percentile, classifying her as obese (Nelms 257). And since the AHA uses the same
charts as the CDC, the results are the same.
According to the WHO, Missys BMI, is in the 99th percentile, which still classifies
her as obese.
B. Calculation of Nutrient requirement
8. If possible, RMR should be measured by indirect calorimetry. Identify
two methods for determining Missys energy requirements other than
indirect calorimetry and than use them to calculate Missys energy
requirements.
Quick estimate (kg X 23= kcal/day): 115 lb/2.2= 52.27 kg X 23= 1200 calories per
day
Mifflin- St. Jeor: [10 x wt (kg) + 6.25 x ht (cm) -5 x age -161]
(10 x 52.27) + (6.25 x 144.8 cm) (5 x 10) -161= 1217 or 1220 calories per day
C. Intake Domain
9. Dietary factors associated with increased risk for overweight are
increased dietary fat intake and increase kilocalorie-dense beverages.
Identify foods from Missys diet recall that fit these criteria. Calculate the
percentage of kilocalories from each macronutrient and the percentage
of kilocalories provided by fluids for Missys 24-hour recall.
Increased dietary fat intake: whole milk, bologna, Frito corn chips, mayonnaise,
Twinkies, fried chicken, fried okra
Increase kilocalorie-dense beverages: apple juice, coffee with cream and sugar,
whole milk, sweet tea, Coca-Cola
Protein: 165 g x 4 kcal= 660 kcals
Carbohydrates: 443 g x 4 kcals=1772 kcals
Fat: 210.8 grams x 9 kcals= 1897 kcals
Total calories per 24-hour recall: 4329 kcals
Missy consumed 946 kcal from fluids, 22% if her daily calories

Nutrients Report 10/06/15 - 10/06/15

Your plan is based on a default 2000 Calorie allowance.

Nutrients

Target

Average Eaten

Status

Total Calories

2000 Calories

4311 Calories

Over

Protein (g)***

46 g

165 g

OK

Protein (% Calories)***

10 - 35% Calories

15% Calories

OK

Carbohydrate (g)***

130 g

443 g

OK

Carbohydrate (% Calories)***

45 - 65% Calories

41% Calories

Under

Dietary Fiber

25 g

20 g

Under

Total Sugars

No Daily Target or
Limit

203 g

No Daily Target or
Limit

Added Sugars

No Daily Target or
Limit

124 g

No Daily Target or
Limit

Total Fat

20 - 35% Calories

44% Calories

Over

Saturated Fat

< 10% Calories

16% Calories

Over

Polyunsaturated Fat

No Daily Target or
Limit

9% Calories

No Daily Target or
Limit

Monounsaturated Fat

No Daily Target or
Limit

15% Calories

No Daily Target or
Limit

Linoleic Acid (g)***

12 g

41 g

OK

Linoleic Acid (% Calories)***

5 - 10% Calories

9% Calories

OK

-Linolenic Acid (% Calories)***

0.6 - 1.2% Calories

0.8% Calories

OK

-Linolenic Acid (g)***

1.1 g

3.6 g

OK

Omega 3 - EPA

No Daily Target or
Limit

30 mg

No Daily Target or
Limit

Omega 3 - DHA

No Daily Target or
Limit

127 mg

No Daily Target or
Limit

Cholesterol

< 300 mg

1033 mg

Over

(USDA Supertracker 2015)

10. Increased fruit and vegetable intake is associated with decreased risk
of overweight. Using Missys usual intake, is Missys fruit and vegetable

intake adequate?
(USDA Supertracker 2015)
Missys fruit and vegetable intake was not adequate. She only ate 73% (1.75 cups)
of her target of 2.5 cups vegetables and 27% (0.5 cups) of her target of 2 cups
fruit. Her fruit intake only came from fruit juice and her vegetables consisted of
mashed potatoes with whole milk and butter and fried okra.
11. Using the MyPyramid Plan online tool to generate a personalized
MyPyramid for Missy. Using this eating pattern, plan a 1-day menu for
Missy.
According to MyPlate, and Missys height, weight, age, and sedentary lifestyle;
Total Calories
Empty Calories
Grains
Whole grains
Vegetables *
Fruits
Dairy

1600 per day

<121 per day
5 oz per day
>3 oz per day
2 cups per day
1.5 cups per day
3 cups per day

Protein Foods
Seafood
Oils

5 oz per day
8 oz per week
5 tsp per day

* More specifically : 1.5 cup dark green, 4 cups red and orange, 1 cup beans and
peas, 4 cups starchy, 3.5 cups other vegetables per week.
12. Now enter and assess the 1-day menu you planned for Missy using
the MyPyramid Tracker online tool. Does your menu meet macro- and
micronutrient recommendations for Missy?
Breakfast
2 scrambled eggs (no added fat)
8 oz skim milk
1 medium apple
Cinnamon and spice oatmeal (1
packet)
Water
Lunch
Turkey Sandwich on whole wheat
bread ( 3 medium slices turkey)
Baked Lays potato chips
1 cup carrots
Water or zero calorie drink
Snack
1 cup celery
2 Tbsp. Peanut butter (reduced fat)
Dinner
1 medium grilled chicken breast
(skinless)
1 cup green beans (no salt or fat
added, maybe add Mrs. Dash for
flavor)
1 medium whole wheat roll
8 oz skim milk
Water
Snack
8 oz fat free yogurt
1 cup berries

Missy's Nutrients Report 10/06/15 - 10/06/15

Your plan is based on a 1600 Calorie allowance.

Nutrients

Target

Average Eaten

Status

Total Calories

1600 Calories

1675 Calories

Over

Protein (g)***

34 g

126 g

OK

Protein (% Calories)***

10 - 30% Calories

30% Calories

OK

Carbohydrate (g)***

130 g

207 g

OK

Carbohydrate (% Calories)***

45 - 65% Calories

49% Calories

OK

Dietary Fiber

26 g

30 g

OK

Total Sugars

No Daily Target or
Limit

95 g

No Daily Target or
Limit

Added Sugars

No Daily Target or
Limit

17 g

No Daily Target or
Limit

Total Fat

25 - 35% Calories

23% Calories

Under

Saturated Fat

< 10% Calories

5% Calories

OK

Polyunsaturated Fat

No Daily Target or
Limit

5% Calories

No Daily Target or
Limit

Monounsaturated Fat

No Daily Target or
Limit

9% Calories

No Daily Target or
Limit

Linoleic Acid (g)***

10 g

9g

Under

Linoleic Acid (% Calories)***

5 - 10% Calories

5% Calories

OK

-Linolenic Acid (% Calories)***

0.6 - 1.2% Calories

0.2% Calories

Under

-Linolenic Acid (g)***

1.0 g

0.5 g

Under

Omega 3 - EPA

No Daily Target or
Limit

13 mg

No Daily Target or
Limit

Omega 3 - DHA

No Daily Target or
Limit

81 mg

No Daily Target or
Limit

Cholesterol

< 300 mg

585 mg

Over

Minerals

Target

Average Eaten

Status

Calcium

1300 mg

1561 mg

OK

Potassium

4500 mg

4016 mg

Under

Sodium**

< 2300 mg

2513 mg

Over

Copper

700 g

1303 g

OK

Iron

8 mg

13 mg

OK

Magnesium

240 mg

426 mg

OK

Phosphorus

1250 mg

2134 mg

OK

Selenium

40 g

156 g

OK

Zinc

8 mg

13 mg

OK

Vitamins

Target

Average Eaten

Status

Vitamin A

600 g RAE

1818 g RAE

Over

Vitamin B6

1.0 mg

2.7 mg

OK

Vitamin B12

1.8 g

5.6 g

OK

Vitamin C

45 mg

51 mg

OK

Vitamin D

15 g

7 g

Under

Vitamin E

11 mg AT

9 mg AT

Under

Vitamin K

60 g

98 g

OK

Folate

300 g DFE

431 g DFE

OK

Thiamin

0.9 mg

1.6 mg

OK

Riboflavin

0.9 mg

3.0 mg

OK

Niacin

12 mg

36 mg

OK

Choline

375 mg

598 mg

OK

Though this one day meal plan does not perfectly meet all macro and micro
nutrient recommendations (ie potassium was under recommended amount), it is a
good representation of one day and she needs to continue to vary her diet to
ensure she receives adequate nutrients over the week. She should also continue to
vary her fruits and vegetables, consume low or no calorie drinks, and try low-fat
items this will ensure she meets her calorie needs and all of her micro nutrient
needs.
D. Clinical Domain
13. Why did Dr. Null order a lipid profile and blood glucose test?
Dr. Null ordered a lipid and blood glucose test because obese patients tend to have
a bad lipid profile (ie high cholesterol, high LDL cholesterol, low HDL cholesterol
and high triglycerides), all of which are serious risk factors for other complications
such as cardiovascular disease, hypertension or heart disease. He ordered the
blood glucose test to check for the possibility of diabetes since Missy is obese and
has a family history.
14. What lipid and glucose levels are considered to be abnormal for the
pediatric population?
For patients 8 years and older with an LDL concentration of 190 mg/dL (or 160
mg/dL with a family history of early heart disease or 2 additional risk factors
present or 130 mg/dL if diabetes mellitus is present), pharmacologic intervention
should be considered. The initial goal is to lower LDL concentration to <160 mg/dL.
However, targets as low as 130 mg/dL or even 110 mg/dL may be warranted when
there is a strong family history of CVD, especially with other risk factors including

obesity, diabetes mellitus, the metabolic syndrome and other higher-risk situations
(Daniel).
15. Evaluate Missys lab results.
Glucose

Normal range
70-110 mg/dL

11/20
108 mg/dL

HDL-C

>55 mg/dL

50 mg/dL

HbA1C

3.9-5.2 %

5.5%

Comments
Though it is still
within the normal
range, it is on the
higher end which
raises some
concern
This decrease in
HDL-C is an affect
of her poor diet
Though higher
than the normal it
is not quite high
enough for a
diagnosis of prediabetes (5.7%),
however it is
close and should
be monitored.

E. Behavioral-Environmental Domain
16. What behaviors associated with increased risk of overweight would
you look for when assessing Missys and her familys diet?
I would look for decreased physical activity, a habit of snacking on large quantities
of food between meals, overconsumption of food a mealtime, improper hydration,
level of stress, lack of sleep, how Missys parents prepare the food, and if Missys
parents use food as a parenting tool, such as for a reward. All of these factors can
lead to being overweight and obese, but they are also behaviors that can be
addressed and changed.
17. What aspects of Missys lifestyle place her at risk for overweight?
Missys lack of physical activity and her schools discontinuation of physical activity
classes, family history of type 2 and gestational diabetes, overconsumption of
calories and fat, the way her parents prepare her food (ie fried protein and
vegetables) and her lack of sufficient sleep. Because of her obstructive sleep

apnea, Missy is very tired in the morning, this might lead her to eat more
comfort foods as well as sitting on the couch playing video games. Also, Missys
medical records say that she has been overweight most of her life, which increases
her chances of being overwight in adulthood. As a result, getting her weight under
control now is imperative
18. You talk with Missy and her parents. They are all friendly and
cooperative Missys mother asks if it would help for them no to let Missy
snack between meals and to reward her with dessert when she exercises.
What would you tell them?
I would tell them that excessive snacking between meals is not beneficial, but
since the body needs nutrients about every 4 hours, preparing a healthy snack mid
morning and in the afternoon, such as a protein and produce, might keep Missy
from over consuming at meal times and feeling tired. As for rewarding her with
food, I do not believe this is a wholesome strategy. Rewards should not be food
related, but more experience related; for example, going to a movie or getting her
nails done. This will teach her that food is not a reward, but is rather what we use
to nourish our bodies. I suggest that Missy and her parents make a list of her
favorite snack foods and allow her to have one every once and awhile, when it is
planned. That way she can look forward to it, feel satisfied, and it can be
consumed in a controlled manner and in moderation.
19. Identify one specific physical activity recommendation for Missy.
The U.S. department of Health and Human Services recommends that young
people aged 6-17 participate in 60 minutes of physical activity daily to improve
strength and endurance, help build healthy bones and muscles, help control
weight, reduce anxiety and stress, increases self-esteem, and may improve blood
pressure and cholesterol levels (CDC). However, with the discontinuation of
physical activity at Missys school and her symptoms of obstructive sleep apnea, I
would recommend that Missy try and get 30 minutes of physical activity 3-5 days
per week. This increase from her sedentary lifestyle would be very beneficial and
as her energy increases she should increase it to 5-7 days per week for 60 min. I
would also recommend that she get this exercise in the form of sports or other
outdoor activities. Throwing her into the gym or on the treadmill at such a young
age would not be beneficial and would put more pressure on her to look a certain
way.
IV. Nutrition Diagnosis

20. Select two high-priority nutrition problems and complete PES

statements for each
1. Excessive energy intake (NI-1.2) related to overconsumption of calorie dense
and high fat foods as evidenced by 24-hour recall and BMI (25 kg/m2) in the 97th
percentile for her age.
2. Physical inactivity (NB-2.1) related to lack of energy from obstructive sleep
apnea symptoms and lack of support as evidenced by patients statement about
schools discontinuation of physical activity, interest in playing video games,
complaints of feeling tired and falling asleep at school, and BMI (25 kg/m2) in the
97th percentile for her age.
(eNCPT Web Publication)
V. Nutrition Intervention
21. For each PES statement written, establish an ideal goal (based on
signs and symptoms) and appropriate intervention (based on etiology).
1. Goal: Reduce caloric intake over time to recommended amount of 1600
kcal/day, reduce intake of high fat foods, increase vegetable and fruit consumption
to 2 cups of each/day, lose 1 lb/ month since she has a serious medical condition
associated with her obesity, obstructive sleep apnea.
Intervention: I would begin intervention with nutrition education for Missy and
her family. Based on her 24-hour recall and the fact that her parent are preparing
her meals, both parties need basic nutrition education to begin to make changes.
This would be done in 1-2 sessions and stress the importance of slowly decreasing
her high fat intake by switching to low fat or skim milk and avoiding fried and
highly processed sugary foods, increasing vegetable and fruit consumption, and
limiting portion sized. Portion sizes are very important teaching tool for children
and MyPlate is a great resource for Missy and her family to use to continue
education and get a better picture of what a normal and recommended diet looks
like. After this initial education, individualized nutrition counseling would be
necessary to continue education and track her progress, meeting 1-2x per month.
Other recommended behaviors that are show consistent association with
decreased obesity or energy balance include:
- Limit her consumption of sugar sweetened beverages (ie apple juice and
sweet tea)
- Limit TV to one hour per day
- Remove TV from primary sleeping area

Eat a healthy breakfast daily

Limit eating out
Encourage family meals
Limit portion sizes

2. Goal: Increase physical activity to at least 30 min a day 3-5x per week, then
increase to 5-7 days a week when Missy has more energy, and eventually to 60
minutes per day.
Intervention: I would encourage Missy to limit screen time to 1 hour a day and
spend the rest of her time outside participating in some sort of physical activity.
She could do this by joining a sports team or riding a bike. Since her school no
longer offers physical education, this will have to be done after school hours, so I
would encourage her family to join her! And on the weekends, they could go hiking
or exploring the outdoors as a family. This will teach Missy that exercising can be
fun and rewarding as opposed to forcing her on a treadmill.
22. Mr. and Mrs. Bloyd ask about using over-the-counter diet aids,
specifically Alli (orlistat). What would you tell them?
I would tell them that Alli is not recommended for anyone under the age of 18 and
that no diet pill is approved for anyone under the age of 16. The over-the counter
diet aid might seem like a great quick solution, but Missy needs to learn proper
nutrition and make behavioral changes. Taking a pill may or my not help her loose
weight, but when she is older the weight will come right back since she will not
have the proper skills and knowledge.

23. Mr. and Mrs. Bloyd ask about gastric bypass surgery for Missy. What
are the recommendations regarding gastric bypass surgery for the
pediatric population?
Factors that should be considered before a child or teenager has gastric bypass
surgery include:
The child has not been able to lose weight while on a diet and exercise program
for at least 6 months, while under the care of a physician.
The teenager should be finished growing (usually 13-years-old or older for girls
and 15-years-old or older for boys).
Parents and the teen must understand and be willing to follow the many lifestyle
changes that are necessary after surgery.

Though it can be very beneficial for weight loss in children, I would recommend
that Missy and her parents consult with her doctor and maybe try diet and
exercise first and wait to re-evaluate when she is full grown (CDC 2015).

VI. Nutrition Monitoring and Evaluation

24. When should the next counseling session with Missy be scheduled?
A nutrition education session should be scheduled as soon as she is available to
jumpstart her knowledge and behavior change. The next counseling session should
be scheduled within a month after her initial visit.
25. Should her parents be included? Why or why not?
Yes her parents should be included since she is a child and they are providing and
cooking her meals. Based on her 24-hour recall her parents have a nutrition
knowledge deficit that needs to be addressed so that they can properly support
and aid in their daughters weight loss. Missys parents will play a vital role in her
weight loss and will have the responsibility of tracker her dietary intake, physical
activity, and screen time. They will have to have the knowledge and skills to
properly support Missy and this can be taught through Missys nutrition counseling
sessions as well as possibly their own separate sessions. I also wanted to mention
that weight loss in children requires a multidisciplinary approach. Missys
obstructive sleep apnea is a serious condition related to her obesity and needs to
be treated by her physician, nurse, dietician, social worker, and psychologist.
26. What would you assess during this follow-up consultation?
During her next follow up consultation I would assess her weight and any weight
loss or gain, a three-day food diary, and her progress on increasing physical
activity. Additionally I would asses her sleep and energy levels as well as her lipid
profile. I would hope to see her HDL cholesterol increased, her HbA1c decreased, to
reduce risk for type 2 diabetes, and a loss of about one pound. I would then assess
her current readiness to change and possible barriers she is encountering (i.e.
support from family or school) and react accordingly. If I notice and psychological
symptoms like depression or low-self-esteem I would talk with her doctor about
referring her to a social worker or psychologist.

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Daniels SR et al. Lipid screening and cardiovascular health in childhood. Pediatrics
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Nelms, M. (n.d.). Nutrition Therapy and Pathophysiology (Third ed.).
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Romero-Corral, A., Caples, S. M., Lopez-Jimenez, F., & Somers, V. K. (2010).
Interactions Between
Obesity and Obstructive Sleep Apnea: Implications for Treatment. Chest,
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