KNH411
10.12.15
CaseStudy#1WeightManagementChildhoodObesity
1.)
Currentresearchindicatesthatthecauseofchildhoodobesityis
multifactorial.Brieflydiscusshowthefollowingfactorsarethoughttoplayarolein
thedevelopmentofchildhoodobesity;biological(geneticsandpathophysiology);
behavioralenvironmental(sedentarylifestyle,socioeconomicstatus,modernization,
culture,anddietaryintake);andglobal(society,community,organizational,
interpersonal,andindividual).
a.)Geneticsplayaroleinthedevelopmentofchildhoodobesityduetothefactthat
childrenarepredisposedtobeoverweightorobeseiftheirparentswereeitheroverweight
orobese.Ithasbeenfoundthatifamotherisobeseduringherpregnancy,thatchildhasa
doubledriskofbeingobese;ascomparedtochildrenofnonobeseparents,therisk
increases13to15%.
b.)Individualsfromallenvironmentshaveachancethattheywilldevelopaweightissue.
However,ithasbeenproventhatchildrenfromlowsocioeconomicstatusaremostprone
tobeingmalnourishedandoverweightasaresultoflimitedaccesstonutritiousfoods,
and/orfinancialbarriersinacquiringnutritiousfoods(foodinsecurity).Areasoflow
socioeconomicstatusaregenerallymoreunsafe,thereforephysicalactivityishardfor
childrentoget,andthemoresedentaryalifestyletheylive.
c.)Ethnicgroupstendtousecookingandeatingasaculturalexperience;eachwith
distinctivefoodstheytendtoprefer.AfricanAmericans,forexample,haveanincreased
riskofbeingoverweight,havingCVD,HTN,andtype2DM.Thiscanbeattributedto
thefactthatAfricanAmericancommunitiestendtobelocatedinlowsocioeconomic
regions,andthereforeculturallyhaveadaptedlotsofprocessed,fatty,friedfoods.
d.)Aswehavebecomemoremodernizedasasociety,ourchildrenhavebecomeusedto
aworldfulloftechnology.ThistechnologyisintheformofTVs,smartphones,tablets
etc.thatallincreaseoursedentarylifestyle.Youthpreferpartakinginvideogamesrather
thanbeingoutside.Thesetechnologiesarestimulatingtheirbrainactivity,andcanresult
inshortenedsleepdurations.Studiesprovethatchildrenwhosleeplessthan10hoursper
nightare245%morelikelytobecomeoverweightthanthosechildrenwhoreceive12to
13hoursduetotheimpactonleptinandghrelinthatregulateappetiteandmetabolism.
e.)Childrenintodayssocietyalsoareexposedtomorecaloriedensefoods;an
approximate120calorieincreasefrom1977to1996.Thisdietarychangeiscorrelated
withincreasingfoodoptionsthatareprocessed,highfat,andfullofhighfructosecorn
syrup(HFCS).WhiletheysitandwatchTV,theymaydrinkasoda.Whiletheyplay
theirgames,theymaychowdownonsomepotatochips.Theygooutforahappymeal
andarefedhamburgerswithFrenchfriesandasoda.Allthesewillultimatelyleadto
weightgain.
f.)Asasociety,wehavenormswhenitcomestoeating.Inrecenttimesthishas
becomeanincreaseinportionsizes,fastfoodrestaurants,andconveniencestorefoods.
Whatweeatdependsonwhatisavailabletousinourcommunity.Ourcommunitiesmay
pridethemselvesoncertainfoods,suchasBBQinTexas.Wearealsoinfluencedby
friendsandfamilymemberstoeatcertainfoods,andcertainreligionsmayrestrictyour
dietoptions.Allofthesecontributetowhatweconsumeonanindividuallevel.
Cited:Childhoodobesitycausesandconsiderations.ObesityAction.Web.
http://www.obesityaction.org/educationalresources/resourcearticles2/childhood
obesityresourcearticles/childhoodobesitycausesandconsiderations2
2.)
Describehealthconsequencesassociatedwithanoverweightcondition.
Describehowthesehealthconsequencesdifferforoverweightversusanobese
condition.
a.)HealthconsequencesassociatedwithbeingoverweightincluderiskofCVD
(includingCHDandCVA),type2DM,somecancers(suchasbreastandcolon),aswell
asosteoarthritis.
b.)Riskfactorssuchasthoselistedabovein2astartwhenanindividualisonlyslightly
overweight.However,asmoreexcessweightisgainedleadingtoobesitythe
probabilityofdevelopingonofthemanyhealthconsequencesandconditionsare
increaseddrastically.
Cited:Whatarethehealthconsequencesofbeingoverweight?WorldHealth
Organization.Web.http://www.who.int/features/qa/49/en/
3.)
Missyhasbeendiagnosedwithobstructivesleepapnea.Definesleepapnea.
Explaintherelationshipbetweensleepapneaandobesity.
a.)MayoClinicdescribessleepapneaasadisorderinwhichbreathingstopsandstarts
repeatedlyduringsleep.Sleepapnea,dependingonitsseverity,hasthepotentialtohave
serioushealthconsequences.Symptomsmayincludeloudsnoring,varyinglengthsof
breathingcessationsduringsleep,abruptlyawakening,headaches,drymouthorsore
throat,insomnia,hypersomnia,attentiondeficits,andirritability.Therearethreemain
categoriesofsleepapnea:
1.Obstructivesleepapnea(OSA)isthemostcommonform,occurringwhenthemuscles
inthethroatrelax.LoudsnoringisacommonsymptomwithOSA.
2.Centralsleepapneaoccurswhenthebrainsignalsarenoteffectivelysenttothe
musclesthatcontrolbreathing.Thistypeisusuallyaccompaniedbyawakeningabruptly,
followedbyshortnessofbreath.
3.Complexsleepapneasyndrome(alsoreferredtoastreatmentemergent centralsleep
apnea)isacombinationofbothOSAandcentralsleepapnea.
b.)Duetohavingexcessweightwhenoverweightorobese,obstructiontobreathingasa
resultoffatdepositsaroundtheupperairwaycanoccur.Althoughsleepapneaisnot
alwayscorrelatedwithcarryingexcessweight,thosewhoareoverweightorobesehave
beenshowntohavefourtimestheriskofsleepapneaasopposedtothoseatahealthy
weight.
Cited:Sleepapnea.MayoClinic.Web.http://www.mayoclinic.org/diseases
conditions/sleepapnea/basics/definition/con20020286
4.)
Whatarethegoalsforweightlossinthepediatricpopulation?Underwhat
circumstancesmightweightlossinoverweightchildrenmaynotbeappropriate?
a.)Forweightlossconcerningoverweightandobesepediatricclients,thegoalistoget
thechildatorunderthe85thpercentile.Duetothefactthatyoungchildrenspecifically
infantsandtoddlersareinvitalstagesofgrowthanddevelopment,weightlosswould
notbeadvised.Weightlossatthisagemayactuallystuntdevelopment.Periodsofweight
gainmayalsooccurduringpubertylaterinchildhood.Ifthechildisobeseandoverthe
ageof6yearsold,nomorethan2lbs./weekweightlossshouldbeachieved,fortheyare
alsocontinuingtheirgrowthanddevelopmentthroughoutchildhood;creatingtoomuch
ofacaloriedeficitatthesetimescouldhinderbothphysicalandcognitivematurity.
Cited:AchievingaHealthyWeightinChildren.EastCarolinaUniversity.
5.)
Whatwouldyourecommendasthecurrentfocusfornutritionaltreatmentof
Missysobesity?
a.)IwouldfocusMissystreatmentonprovidingherselfandherfamilypropernutrition
andphysicalactivityeducation.Fromher24hourdietrecall,itisclearthatsheisbeing
providedwithanoverabundanceoffood,butnotanabundanceofnutritiousfoods.Her
dietisprominentlymadeupofhighcalorie,highfatfoods,andhighcalorie,highsugar
beverages.Fromhernutritionhistoryitisalsoveryapparentthatontopofconsumingin
excess,sheisnotgettingenoughphysicalexercise.Ifshedoesnotchangeherdietand
exercisehabits,hermedicalissuesresultingfromherobesitywillonlycontinueto
worsen.Mymainfocuswouldbetointroducemorefruitsandvegetablesanderadicate
highcaloriedrinksfromherdiet.
6.)
OverweightorobesityinadultsisdefinedbyBMI.Childrenandadolescents
areoftentimesclassifiedasoverweightoratriskforoverweightbasedontheir
BMIpercentiles,butthisclassificationschemeisbynomeansuniversallyaccepted.
Usethreedifferentprofessionresourcesandcompare/contrasttheirdefinitionsfor
overweightconditionsamongthepediatricpopulation.
a.)TheCenterforDiseaseControlandPrevention(CDC)generallydefinesoverweight
ashavingexcessbodyweightforaparticularheightfromfat,muscle,bone,water,ora
combinationofthesefactors;obesityisdefinedashavingexcessbodyfat.TheCDC
usesBMIinordertomeasurechildhoodoverweightandobesitythatareageandsex
specific.TheyexpressoverweightasaBMIfallingbetweenthe85thand95thpercentile.
ObesityiscategorizedasaBMIfallingabovethe95thpercentile.CDCgrowthcharts
shouldbeusedwhenevaluatingchildren2yearsandolder.
Cited:Definingchildhoodobesity.CDC.Web.
http://www.cdc.gov/obesity/childhood/defining.html
b.)TheWorldHealthOrganization(WHO)launchedanindependentreferenceforchild
growthstandardsinApril2006thatevaluatesweightforage.Agegroupdividesgrowth
standardsforthoseininfancyuptoage5,individualsbetween519years,andforadults.
WHOspecifiesthosewithaBMIgreaterthanorequalto25asoverweight,whileaBMI
ofgreaterthanorequalto30indicatesobesity.Whendetermininggrowthstatus,Z
scores(standarddeviationscores)areusedtocompareachildsobservedBMIwiththe
medianvalueabdstandarderrorofthereferencepopulationinordertoachievemore
accuratemeasurements;zscoresaresexdependent.WHOgrowthstandardsshouldbe
usedwhenmonitoringgrowthofinfantsandchildrenuptoage2.
Cited:Childgrowthstandards.WorldHealthOrganization.Web.
http://www.who.int/childgrowth/en/
c.)ChildrensHospitalColoradodevelopednewgrowthchartsbasedofftheCDCs
growthchartsfrom2000,whichdidnotdistinguishbetweensubgroupsofobesechildren
onceBMIpercentileswentabovethe97thpercentile.ThesechartsdefineBMIasa
percentageofthe95thpercentile.
Cited:Clinicaltrackingofseverelyobesechildren:anewgrowthchart.Pediatrics.
7.)
EvaluateMissysweightusingtheCDCgrowthchartsprovided.Whatis
MissysBMIpercentile?Howwouldherweightstatusbeclassifiedbyeachofthe
standardsyouidentifiedinquestion6?
a.)Missywouldfallinthe97thpercentilewhenusingtheCDCsBMIforagepercentiles
growthchartforgirlsages2to20years.Sinceshefallsoverthe95thpercentile,Missy
wouldbeclassifiedasobesebythesestandards.
Calculations:
BMI=(Weight(kg)/(Stature(cm)2)x10,000
or
BMI=(Weight(lb.)/(Stature(in)2)x703
BMI:(115lb./(57in)2)x703=24.88=25
b.)Missyiscategorizedasobese(inthe97thBMIpercentile)byeachofthestandards
identifiedinquestion6.
8.)
Ifpossible,RMRshouldbemeasuredbyindirectcalorimetry.Identifytwo
methodsfordeterminingMissysenergyrequirementsotherthanindirect
calorimetryandthenusethemtocalculateMissysenergyrequirements.
a.)CalculateMissysestimatedenergyrequirement(EER)estimateddailycalories
neededtomaintainhercurrentweight.HerEERcameouttoberoughlybetween1700to
1800kcal/day.
Calculations:
Forgirlsage318:EER=(135.3(30.8xage))+PAx((10xwt.)+(934xht.))
*weightinkg,heightinm,ageinyears.PAforphysicalactivitycoefficient(PA
of1forsedentary).
Height:57inx(2.54cm/1in)=144.78cm=145cmx(1m/1000cm)=1.45m
Weight:115lb.x(1lb./2.2kg)=52kg
EER=(135.3(30.8x10yo))+1x((10x52kg)+(934x1.45m))
EER=1727=17001800kcals/day
b.)CalculateMissystotalenergyexpenditure(TEE)usingtheHarrisBenedictEquation
forbasalmetabolicrate(BMR),alsotermedBEEtheminimumamountofenergy
requiredtocarryoutbasicmetabolicfunctionsdaily.TEEistheestimatedamountof
caloriesburneddaily,adjustedtoactivitylevelforanindividual.MissysBEEcameout
tobe1368kcal/day.Afterheractivityfactor(AF)wastakenintoconsideration,TEE
wascalculatedtobe16001700kcal/day.
Calculations:
BEE =655+9.6(wt.)+1.8(ht.)4.7(age)forfemales
=655+(9.6x52kg)+(1.8x145cm)(4.7x10)
=1368kcal/day
TEE=BMRxAF
TEE=1368x1.2=1642kcal/day
AF=1.2(sedentary,littletonoexercise)
*weightinkg,heightincm,ageinyears.
9.)
Dietaryfactorsassociatedwithincreasedriskofoverweightareincreased
dietaryfatintakeandincreasedkilocaloriedensebeverages.Identifyfoodsfrom
Missysdietrecallthatfitthesecriteria.Calculatethepercentageofkilocalories
fromeachmacronutrientandthepercentageofkilocaloriesprovidedbyfluidsfor
Missys24hourrecall.
a.)FromMissys24hourrecall,itisconfirmedthatherdietishighinbothincreased
dietaryfatintakeandkilocaloriedensebeverages:
Kcal-Dense
High-Fat Items
Beverages
Apple juice,
AM
whole milk
Lunch
Snack
Whole milk
Whole milk
Sweet tea
Coca cola
b.)UsingSuperTracker,thepercentageofmicronutrientcaloriesoutoftotalkilocalories
forthedayofthe24hourdietrecallwerecalculated.Missystotalcaloriecountwas
4587kcal,with17%kcalscomingfromprotein,47%fromfat,and36%from
carbohydrates.Fluidsmadeup20%ofMissystotalcaloriecountfortheday.
AMOUN
AM
LUNCH
ITEM
Breakfast
T
KCAL
2 burritos
Burrito
Whole Milk
Apple Juice
Coffee
Cream
Sugar
Bologna
American
8 oz.
4 oz.
6 oz.
1/4 c
2 tsp
2 slices
PRO(g)
FAT (g)
CHO (g)
613
149
57
2
79
33
174
32
8
0
0
2
0
6
37
8
0
0
7
0
16
36
12
14
0
3
8
2
Cheese
White Bread
Mayo
2
4
2
1
slices
slices
tbsp
oz.
141
277
198
8
8
0
11
3
22
3
53
1
package
2
145
18
Twinkie
Whole Milk
Crunch Peanut
Twinkies
8 oz.
187
149
2
8
6
8
32
12
SNACK
Butter
Grape Jelly
White Bread
Whole Milk
2 tbsp
2 tbsp
2 slices
12 oz
2 legs, 1
190
101
138
223
8
0
4
12
16
0
2
12
6
27
26
18
DINNER
Fried Chicken
Mashed
thigh
837
92
50
Potatoes
Fried Okra
1c
1c
212
177
4
5
6
8
37
22
SNACK
Sweet Tea
Popcorn
Coca Cola
TOTAL
20 oz.
3c
12 oz
119
250
136
4587
0
3
0
204
0
20
0
240
Calculations:
PRO:204gPROx4=816kcalPRO/totalkcal4587=.18x100=17%PRO
FAT:240gFATx9=2160kcalFAT/4587totalkcal=.47x100=47%FAT
CHO:413gCHOx4=1652kcalCHO/4587totalkcal=.36x100=36%CHO
FLUIDS:914kcalFLUIDS/4587totalkcal=.20x100=20%FLUIDS
Cited:SuperTracker.USDA.Web.www.supertracker.usda.gov
10.)
Increasedfruitandvegetableintakeisassociatedwithdecreasedriskof
overweight.UsingMissysusualintake,isMissysfruitandvegetableintake
adequate?
a.)AccordingtotheUSDAsMyPlateguidelines,a1600caloriedietfor917yearolds
shouldinclude2cupsofvegetablesand1cupsoffruitdaily.Besidesthe4oz.of
applejuiceconsumedbyMissyinher24hourdietrecall,shedidnothaveanyother
sourcesoffruit;MyPlateemphasizesgettingdailyfruitintakesfromwholeorcutup
fruitsratherthanfromfruitjuices.Asforvegetables,sheonlyconsumed1cupofOkra
and1cupofmashedpotatoes.Thiswouldsuggestshemetherdailyrecommendations
of2cupsofvegetables,however,itshouldbenotedthatbothchoicescontributedtoher
highfatdiet;theOkrawasfried,andthemashedpotatoeswerepreparedwithbutterand
wholemilk.
Cited:ChooseMyPlate.USDA.Web.www.choosemyplate.gov
11.)
UsingtheMyPlateplanonlinetool(availableatwww.choosemyplate.gov;
clickoninteractiveTools,thenDailyFoodPlans&Worksheets)togeneratea
personalizedMyPlateforMissy.Usingthiseatingpattern,plana1daymenufor
31
17
35
413
Missy.
a.)MissysMyPlate(basedoff1600caloriediet):
AM:
BreakfastBurrito(1largeegg,3tbsp.eggwhites,cupshreddedcheddarcheese,1
wholewheattortilla)
1apple
8oz.skimmilk
LUNCH:
Turkeysandwich:(3oz.deliturkeybreast,1thickslicetomato,1tbsp.MiracleWhip,2
sliceswholewheatbread)
cbabycarrotswith2tbsp.hummus
cseedlessgrapes
8oz.Water
SNACK:
6wholewheatcrackerswith2tbsp.crunchpeanutbutter
8oz.water
DINNER:
1mediumchickenbreast(boneless,skinless,baked)
cgreenbeans(nosaltorfatadded)
1mediumbakedpotato(nosaltadded,peelnoteaten)
8oz.skimmilk
SNACK:
cplain,fatfreeyogurtwithcslicedstrawberries
1cpopcorn(nobutteroroiladded)
8oz.water
12.)
Nowenterandassessthe1daymenuyouplannedforMissyusing
SuperTrackeronlinetool(www.supertracker.usda.gov).Doesyourmenumeet
macoandmicronutrientrecommendationsforMissy?
a.) MyproposedmenumeetsallofthemacronutrientrecommendationsforMissy.If
Missyfollowedthissamplemenu,shewouldbeeatingjustabovetherecommended
1600totalkcaldiet(withapproximately1660kcalsforthisparticularmealplan).
Shewouldbeat28%oftotalkcalcomingfromprotein,whichisonthehighofthe
recommendedrangeof1030%.Hercarbohydrateswouldcomeouttobeabout47%
oftotalkcal(acceptedrange4565%).Hertotalfatwouldbe27%oftotalkcal
(withinrangeof2535%),andhersaturatedfatintakewouldstaybelow10%total
kcal,atapproximately8%.Thesepercentagesareconsistantwithaususalnutrition
prescriptionformodifiedcarbohydratemealplanninguseforpediatricwieght
management:40%CHO,30%PRO,30%FAT.Shewouldalsosignificantlydecrease
hercaloricintakefromfluids,asIhavesuggestedamealplanvoidofhighsugarand
highfatdrinks;substituingwaterforsodaandteas,andwholemilkwithskimmilk.
Cited:AchievingaHealthyWeightinChildren.EastCarolinaUniversity.
b.) Majorityofmicronutrientsneedsarealsometwiththisdietplan.Mineralssuchas
calcium,iron,magnesium,phosphorous,selenium,copperandzincrecommendations
wereallreached.VitaminsA,B,C,andEreachedtheirtargets,aswellasfolate,
thiamin,riboflavin,niacin,andcholine.Sodiumwasconsumedinslightexcess,at
2431mg(overthe>2300mgtarget).Potassiumwastheonlymineralthatisunderits
targetgoal,aswellasvitaminD&K.Allofthesevalueswouldreach
recommendationsifMissycontinuestotakeherdailyFlinstonesmultivitamin.
13.)
WhydidDr.Nullorderalipidprofileandbloodglucosetest?
a.)DuetothefactthatMissyfallswithinthe97thpercentileofBMIforage,sheis
consideredobese.Missyisincreasinglysusceptibletocomorbiditiesandfutureobesity
becauseofherfamilyhistoryofgestationaldiabtes,type2DM,myocardialinfarction
(MI),andhighbloodpressure(HBP)onhermaternalside.Additionally,shehasapartial
africanamericanethnicityandisgoingthroughpuberty,whichbothincreaseher
probabilitiesforfutureimplications.TheCDChasfoundthatprediabetesisincreasingly
prevalentinobeseadolescents,placingthemathighriskfordevelopingtype2DM.Dr.
Nullwouldorderabloodglucosetestsincebloodglucoselevelsareevaluatedwhen
lookingtodiagnosisapatientwithprediabetesortype2DM.
b.)IncreasedrisksfactorsforCVDsuchashighcholesterol(HC),highbloodpressure
(HBP)orhypertension(HTN)arecorrelatedwithobesity;70%ofobeseyouthhaveat
leastoneriskfactorofCVD.Dyslipidemiaisalsoassociatedwithobesityandriskof
CVD,andiscategorizedbyhighTC,TGs,andLDL,aswellaslowlevelsofHDL;
dyslipidemiacanbetestedwithalipidprofile.Thelipidprofilewillindicateif
cholesterolisbeginning,orhasalreadybegun,todamageandblocktheendothelialcells
ontheinteriorliningofherveinsandarteries.
Cited:Childhoodobesityfacts.CDC.Web.
http://www.cdc.gov/healthyschools/obesity/facts.htm
14.)
Whatlipidandglucoselevelsareconsideredtobeabnormalforthepediatric
population?
a.)Forthepediatricpopulation,normalglucoselevelsshouldfallbetween70100
mg/dL;valuesanywherebetween100125mg/dLmaysuggestprediabetes.Cholesterol
levelsshouldfallbetween120199mg/dL;anything<170mg/dLisconsideredacceptable,
whilelevelsfrom170199mg/dLmaybeconsideredborderline.TGof<200mg/dL,
HDLCof>40mg/dLandLDLof<110mg/dLareallacceptablelevels.Anylabvalues
outsideoftheserangeswouldbeconsideredabnormal.
Cited:AchievingaHealthyWeightinChildren.EastCarolinaUniversity.
15.)
EvaluateMissyslabresults.
a.)Missysglucosewasfoundtobe108mg/dL,whichsuggestspossibleprediabetesby
fallingwithintherangesuggestingso(100125mg/dL).HerTCwasborderline(170
199mg/dL)at190mg/dL.HerHDLCwasat50mg/dL,whichishigherthanthe>40
mg/dLstandardforanacceptableHDLC.MissysLDLof110mg/dLisanacceptable,
howeveralmostborderlinevalue;borderlineLDLbeing>110mg/dLforpediactric
patients.LabresultsindicateherTGof114mg/dLfellwithinthenormalrangeof<200
mg/dL.A1Cistestedasanindicatorfortype2DM;herA1Cresultswerehigherthan
thatoftheacceptedrangeof3.95.2%,at5.5%.HerhighA1Candglucosevalues
indicatethatMissyisprediabeticorpossiblydiabetic.
Cited:AchievingaHealthyWeightinChildren.EastCarolinaUniversity.
16.)
Whatbehaviorsassociatedwithincreasedriskofoverweightwouldyoulook
forwhenassessingMissysandherfamilydiets?
a.)ThetwomostindicativebehaviorswithincreasedriskofoverweightorobesityI
wouldlookforwhenassessingMissyandherfamilydietisexcessivekcalandtotalfat
intake.A24hourrecall,likeMissys,showinghighamountofconsumptionofprocessed
andfriedfoodswouldindicateahighintakeofsaturatedfatsthatwouldalso
unquestionablycontributetobehaviorsassociatedwthincreasedriskofbeing
overweight.Consumptionofcaloricdensebeverageslikesodasandsportsdrinksthat
containhighamountsofaddedsugarsisanotherbehaviorIwouldlookfor.From
Missys24hourrecall,Icouldassumeherparentsdiethabitstobealmostidenticalto
hers;hightotalcalories,totalfat,saturatedfats,sugar,andfriedandprocessedfoods
consumed.Fromthe24hourrecall,itcouldalsobeassumedthatMissyandherfamily
donothaveknowledgeofproperportionsizes.Itmayalsobeadvantageoustodetermine
whoismainlyresponsibleforfeedingthefamily,ifthispersonprovidesmostmealsfor
thefamily,oriftheyeatoutoften.WhenassessingMissy,Iwouldwanttoknowif
mealsareprovidedbytheschool,andifso,howmanymeals,thevarietyoffoodsbeing
provided,andwhattypeoffreedomshehasinherfoodchoices.
17.)
WhataspectsofMissyslifestyleplaceheratincreasedriskforoverweight?
a.)Accordingtohernutritionhistory,shenotonlyhasaheartyappetiteinwhichsheis
consumingmuchmorecaloriesthanherbodyisburning,butsheisverysedentaryrelated
tobudgetcutsatherschoolleadingtodiscontinuingofphysicaleducationclasses.After
school,herhobbiesalsoincludeverysedentaryactivitiessuchasreadingandplaying
videogames.
18.)
YoutalkwithMissyandherparents.Theyareallfriendlyandcooperative.
MissysmotherasksifitwouldhelpforthemtonotletMissysnackbetweenmeals
andtorewardherwithdessertwhensheexercises.Whatwouldyoutellthem?
a.)FromMissys24hourdietrecall,itseemstobethattheproblemisntthatsheis
snackingbetweenmeals,butratherherfoodchoicesandportionsizes.Iwouldsuggest
toMissysmotherthatshecontinuetoletMissysnackinbetweenmeals.Onefearwould
bethatMissy,beingusedtosnacking,wouldfeeldeprivedbymealtimesandgorgeeven
moreonlargequantitiesoffoodifsnackswereomittedfromherdietplan.Iwould
emphasizetheimportanceofmakingthosesnacksnutritious,andinsmallportions;just
enoughtokeepMissycontentuntilhernextmeal.Formysuggestedmealplan,Ihad
listedpeanutbutterwithcrackersandyogurtmixedwithfreshfruitassomesnackoptions
forMissy.Missysmotheralsoneedstorealizethatweightlosswillonlycomefrom
burningmorecaloriesthanarebeingconsumed.IfsherewardsMissywithdessertwhen
sheexercises,thetreatswillmostlikelybecaloriedense,andwillonlyaddbackthe
caloriesMissymayhaveburnedduringherworkout.
19.)
IdentifyonespecificphysicalactivityrecommendationforMissy.
a.)SinceMissyisobeseandlivesaverysedentarylifestyle,recommendingtoomuchor
toovigorousphysicalactivityatfirstmaynotbeeffective.Iwouldsuggeststartingslow
andmakinganefforttogetoutsideeverydaytheweatherpermits.Takingawalkaround
theneighborhoodwouldbeagreatwaytoeaseMissyintogettingmorephysicalactivity.
Asherenduranceincreases,shecanwalkatamorebriskpaceorwalkforlonger.Itmay
alsobeadvantegousformembersofherfamilytojoinheronherwalkstoshowsupport
bymakingitafamilyeffort.
20.)
SelecttwohighprioritynutritionproblemsandcompletePESforeach.
a.)Obesity(NC3.4)relatedtophysicalinactivityasevidencedbyalowphysicalactivity
levelduetodiscontinuedphysicaleducationclassatschool,sedentaryhobbiesofreading
andplayingvideogames,andaBMIinthe97thpercentileforageandgender.
b.)Excessiveenergyintake(NI1.5)relatedtoundesirablefoodchoicesandnutrition
relatedknowledgedeficitasevidencedby24dietrecallconsistingoflargequantitiesof
caloriedensebeveragesinadditiontoprocessedandfriedfoodsresultingin4587total
kcal(recommended1600kcaldiet)with47%oftotalkcalsfromfat,20%oftotalkcals
fromfluids,andaBMIinthe97thpercentileforageandgenderindicatingobesity.
21.)
ForeachPESstatementwritten,establishanidealgoal(basedonsignsand
symptoms)andanappropriateinteventions(basedonetiology).
a.)Obesity
Goal:ReduceBMIto<85thpercentilebyincreasingphysicalactivityto1hourormoreof
moderatetovigourousphysicalactivitydaily,andlimitingvideogametimeto2hoursor
lessdaily.
Intervention:Activelyengagethewholefamilyineducationoverphysicalactivity
includingsuggestionsfortheamountofexerciseneededdaily,waystogetactiveboth
indoorsandoutdoors,establishingexerciseroutines,andhowtogetactivetogetherasa
family.
b.)Excessiveenergyintake
Goal:DecreaseBMIto<85thperentileforageandgenderbyreducingtotalkcals
consumeddailyto16001800kcal,decreasingtotalfattowithin2035%oftotalkcals
(with<10%comingfromsaturdatedfat),andcuttingthetotalkcaldailycomingfrom
fluids.
Intervention:SeeknutritioncounselingfromRDtoprovidenutritioneducationtoentire
familyaboutpropernutritionforMissyandherfamily,including:individualized
nutritionprescription,samplemealplans,handoutsonproperservingsizes,tipsfor
makinghealthyfoodchoices(school,work,home),snackideas,aswellasalternative
listsforcaloriedensebeverages.Cookinglessonsmayalsoprovebeneficialforthe
parents.
Cited:AchievingaHealthyWeightinChildren.EastCarolinaUniversity.
22.)
Mr.andMrs.Bloydaskaboutusingoverthecounterdietaids,specifically
Alli(orlistat).Whatwouldyoutellthem?
a.)AlliistypicallyusedforoverweightandobeseadultswithBMIof>30in
combinationwithadditionalhealthriskfactors.Iwouldnotproclaimittobesafefor
Missytouseinordertoachieveherweightlossgoals(orfortheirownweightloss
goals).Firstandforemost,anutritiousdietalongwithphysicalactivityrecommendations
appropriatetothespecificindivudalshouldbeattemptedinordertodecreaseweightloss
gradually.ThesealoneshouldbeenoughtodropsomeweightandreachandidealBMI
overtime.Otherdisadvantagesincludesideeffectssuchas:areducedabilitytoabsorb
fatsolublenutritions,abdomicalpain,flatulence,frequentand/orhardtocontrolbowel
movements,aswellasheadacheandbackpain.Missyinparticularisalreadysuffering
fromheadachesasaresultofherOSA,soitmaybebesttostayawayfromthisproduct.
Cited:Alliweightlosspill:doesitwork?MayoClinic.Web.
http://www.mayoclinic.org/healthylifestyle/weightloss/indepth/alli/art20047908?pg=2
23.)
Mr.andMrs.BloydaskaboutgastricbypasssurgeryforMissy.Whatare
therecommendationsregardinggastricbypasssurgeryforthepediactric
population?
Bariatricsurgeryshouldonlybeconsideredasalastresortwhendiethasnothadan
effectonsupportingweightlossandcontrollingrelatedhealthissues.Inordertoqualify,
theindividualmusthaveaBMI>40,or>35withadditionalmedicalproblems.Theyalso
mustcompleteamultitudeofstudiesinordertobeapprovedforsurgery,including:
psychologicalevaluation,labwork,sleepstudy,cardiologyevaluation,andbariatric
surgerysupportgroup.Lastly,theindividualmustberecommendedbysurgerybythe
bariatricteaminordertoreceivesurgery.ForMissy,analternativeweightlossprogram
thatincludedpsychologicalandnutritionalcounselingaswellasstrategiesfor
implementingchangeandassistanceinlearninghowtoincreasephysicalactivitywould
besuggestedbeforebariatricsurgerywouldeverbeconsidered.
Cited:Bariatricsurgeryqualifications.NationwideChildrens.Web.
http://www.nationwidechildrens.org/bariatricsurgeryqualifications
24.)
WhenshouldthenextcounselingsessionwithMissybescheduled?
a.)ForpediatricpatientslikeMissyinthe95thto<99thpercentileforBMIforage,the
firststepintreatmentisassessingandcounselinginordertoestablishweightlossgoals
anddeveloptheknowledgeandskillsneededtoachievehealthgoals.Forthisreason,it
issuggestedthefamilymeetswiththeRDevery13months.Thisamountoftime
providesenoughtimebetweensessionsinordertochangehealthrelatedbehaviorsand
seewhetherornottheinterventionisachieveingresults.Iftheinterventionapproachis
noteffective,itcanthenbereevaluatedandchanged.
Cited:AchievingaHealthyWeightinChildren.EastCarolinaUniversity.
25.)
Shouldherparentsbeincluded?Whyorwhynot?
a.)Missyisstillyoungenoughtowheresheisnotyetindependentandmostofher
decisionsregardingherdailyactivitiesareinfluencedbyherparents.Intermsofdiet,
theymostlikelyareinchargeofwhatfoodisbeingbroughtintothehouse,whatmeals
arepreparedatmealtimes,andhowthemealsarebeingprepared.Theyshouldbejustas
activeapartinhertreatment,becausetheyaregoingtobethesupportthatMissyneeds
tomakethechangessheneedstomake.
26.)
Whatwouldyouassessduringthisfollowupcounselingsession?
a.)Inthefollowupcounselingsession(13monthsaftertheinitialsession),Iwouldre
evaluateMissysprogress.Iwouldfirstassessherheight,weight,BMIandpercentile
classificationsforgrowthcharts.ThenIwouldtakealookatherdietaryintakeandphysical
activityrecords,noteanylifestylechangesthathavebeenmade,medicationchanges,aswell
asanevaluationonhercomprehensionoftheinitialmateriallearned.Herinterventionmay
needtobealteredbasedonherneedswithafocusoncontinuingtodevelopselfeffaciacy.At
thispointintheprocess,iftheclientisacceptingofhelpandshowswillingnessstochange,
handoutsmaybeanadditionaltooltousethatwillprovideadditionallearningmaterialuntil
thenextsession.
Cited:AchievingaHealthyWeightinChildren.EastCarolinaUniversity.
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AchievingaHealthyWeightinChildren.(2009,August1).RetrievedOctober1,2015.
BariatricSurgeryQualifications.(n.d.).RetrievedOctober1,2015,from
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