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13 Meghan Ames Mrs. Matuszak KNH 406 February 23, 2010 Understanding the Disease and Pathophysiology Weight Management Case Study #3 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 include genetic influences such as appetite, taste preferences, energy intake, resting energy expenditure, the thermic effect of food, nonexercise activity thermogenesis, and the body s efficiency in storing energy. Behavioral-environmental influences include social influences, such as poverty, food availability, cultural food practices, family values, and availability of resources. Global influences include location of grocery stores, legal restrictions, food resources, extracurricular activities, methods of transportation, fast-food restaurants, and many more factors. 2) Describe health consequences association with an overweight condition. Describe how these health consequences differ for an overweight versus an obese condition. Type II diabetes is three times as prevalent among obese people resulting from elevated plasma free fatty acids, insulin resistance, reduced glycogen stores, and increased hepatic glucose production. These complications are significantly less common in overweight individuals than obese people. Obese individuals are also more likely to have high blood pressure and dyslipidemia. Certain cancers, breathing difficulties, arthritis, and reproductive complications are also associated with obesity. Modest weight loss in an overweight or obese individual and result in reduced risk of certain diseases and improved health. 3) Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea. Explain the relationship between sleep apnea and obesity. Obstructive sleep apnea is a condition resulting in brief cessation of breathing during sleep due to a relaxation of the throat muscles. It is seen more commonly in overweight or obese individuals because extra soft tissue can thicken the wall of the windpipe, restricting the opening. 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?

14 According to the Journal of the American Dietetic Association, there are four main goals for treatment of pediatric obesity: 1) reduce energy intake; 2) increase energy expenditure; 3) actively engage primary caretakers; and 4) facilitate a supportive environment (Kirk, et. al.). Additionally, the child s age and severity of obesity should be considered when prescribing treatment. Obesity in older children can be treated as adults, whereas treatment in younger children may take a more conservative approach, and allow for long-term weight loss over time, resulting from simple lifestyle changes. Aggressive weight loss interventions may be inappropriate for younger children (< 8 years) who are only moderately obese (BMI < 30), as the natural aging process may address weight concerns. 5) What would you recommend as the current focus for nutritional treatment of Missy s obesity? Because Missy is still fairly young, I would focus on intervention efforts that impact Missy s health habits, such as diet and exercise. Rather than setting a daily calorie goal to achieve a certain weight, I would challenge Missy to incorporate certain dietary goals, such as fruits and vegetables, into her daily routine in hopes that a healthier diet would lead to weight loss as she continues to grow. Nutrition Assessment A) Evaluation of Weight/Body Composition 6) Overweight or obesity in adults is defined by BMI. Children and adolescent are oftentimes 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. The Maternal and Child Health Bureau, Health Resources and Services Administration, the Department of Health and Human Services committee of pediatric obesity experts recommends the following criteria for diagnosing obesity in children: BMI 85 th percentile with complications of obesity BMI 95 th percentile with or without complications where complications of obesity include hypertension, dyslipidemias, orthopedic disorders, sleep disorders, gall bladder disease, and insulin resistance (Barlow, et. al.) The American Academy of Pediatrics and the American Dietetic Association both cited pediatric obesity criteria as those with a BMI greater than the 95 th percentile (where children with a BMI greater than the 85% percentile are considered overweight). 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? 59 (1.50 m) and 115 lbs (52.3 kg) BMI = 23.2, 95 th percentile for age

15 Missy s BMI of 23.2 puts her just above the 90 th percentile for her age. According to both the American Academy of Pediatrics and the American Dietetic Association, Missy is considered obese. She could also be classified as obese according to the definition used by the Maternal and Child Health Bureau because her BMI is above the 95 th percentile and she suffers from a sleep disorder, which is a complication of obesity. 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. Alternative methods for finding RMR include direct calorimetry, doubly labeled water, and energy estimation equations. Two equations that could be used to calculate Missy s energy requirements are the Harris Benedict and the IOM for overweight females aged 3 through 18. Harris Benedict: REE = (52.3) (1.50) 4.7 (10) = 1,113 kcal TEE = 1.2 (REE) = 1,336 kcal IOM: TEE = (10) (15.0 * * 1.50) = 1,814 kcal 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. Food Item Exchange Carbohydrate Protein Fat 2 brkfst burritos 4 cho 2 med. fat meat 2 fat oz. whole milk 1 whole milk oz. apple juice 1 fruit 15 6 oz. coffee n/a ¼ c. cream 2 fat 10 2 t. sugar 2 other carb 30 4 slices bread 4 starch oz. bologna 4 high-fat meat oz. cheese 2 high-fat meat T. mayo 3 fat 15 1 oz. corn chips 1 starch fat 5 2 twinkies 4 carb 60 4 fat 20 8 oz. whole milk 1 whole milk slices bread 2 starch T. peanut butter 4 fat 20

16 2 T. jelly 2 carb oz. whole milk 1.5 whole milk pieces (6 oz) fried chicken 6 med-fat meat c. mashed potatoes 2 starch c. fried okra 1 starch fat 5 20 oz. sweet tea 4 carb 60 3 c. microwave popcorn 1 starch fat 5 12 oz. coca-cola 2 carb 30 Total Grams Total Calories Macronutrient Distribution 44% 14% 42% Foods contributing to increased fat include fried chicken, whole milk (instead of 1%), twinkies, bologna, breakfast burritos. High calorie beverages include coca-cola, sweet tea, and coffee with cream and sugar. 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? No. Missy s diet contains no raw fruits or vegetables. The only fruits are in juice or jelly form and the only vegetable is fried. 11) Use the MyPyramid Plan online tool to generate a personalized MyPyramid for Missy. Using this eating pattern, plan a 1-day menu for Missy. Breakfast: 1 piece white bread with jelly, honey nut cheerios with 1% milk, OJ Snack: celery and peanut butter Lunch: ham sandwich with mayo, carrots with low-fat dressing, 1% milk, chocolate chip cookie Snack: yogurt with granola Dinner: chicken breast, broccoli, corn, 1% milk, strawberries Daily goals: 1600 kcal, 5 oz. grains, 2 cups vegetables, 1.5 cups fruit, 3 cups milk, 5 oz. meat/beans 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? The macronutrient ranges were a bit off (56% carb, 22% protein, 25% fat) resulting in a relatively low-fat diet (this is interesting considering that the Menu Planner was alerting

17 me to an excessive fat and oil intake). All of the micronutrient needs were met, with the exception of fiber which was only 18 g. (RDA is 26 g.). D) Clinical Domain 13) Why did Dr. Null order a lipid profile and a blood glucose test? Dyslipidemia and insulin insensitivity are two conditions that are often associated with obesity. Dr. Null ordered these tests to address the possibility that Missy may be experiencing other complications related to her weight. 14) What lipid and glucose levels are considered to be abnormal for the pediatric population? Abnormal glucose levels are < 70 mg/dl and > 110 mg/dl. Abnormal lipid levels include a cholesterol < 120 or > 199 mg/dl, HDL < 55 mg/dl, and LDL > 130 mg/dl. 15) Evaluate Missy s lab results. Missy s lipid levels are all within the normal limits except for her HDL, which is low (50 mg/dl). Her other lipid levels, however, are approaching the high end of the normal range (T-chol is 190 mg/dl and LDL is 110 mg/dl). Glucose is also on the high side of the normal limits at 108 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 diet? Frequent consumption of fast- or prepared-foods, sugary beverages, few fruits and vegetables, large portion sizes, and sedentary lifestyle. 17) What aspects of Missy s lifestyle place her at increased risk for overweight? Diet consisting of few fruits and vegetables, high-fat snacks, and sugary beverages; little physical activity. 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? Focus on a healthy diet, which does not mean skipping snacks, necessarily, but rather including healthy snacks, like celery and peanut butter. Try to take focus off of food by not forbidding foods as punishment nor awarding foods as positive reinforcement. 19) Identify one specific physical activity recommendation for Missy. To incorporate physical activity into Missy s day-to-day life, she might benefit from joining a sports team or even having a Wii Fit so that physical activity does not seem like a chore, but rather is something fun that she looks forward to. Nutrition Diagnosis 20) Select two high-priority nutrition problems and complete PES statements for each.

18 Excessive energy (NI-1.5) and fat intake (NI-51.2) RT dietary selections of high-fat meat and sugary snack products AEB dietary recall (intake exceeding 4,000 kcal and fat distribution of 42%). Food and nutrition-related knowledge deficit (NB-1.1) RT no prior instruction, lack of familial support and disinterest in learning AEB dietary selection of high-fat mean and sugary snack products. Nutrition Intervention 21) For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on etiology). Reduce energy intake to 1800 kcal per day by selecting low-fat meats and low-calorie snacks. Plan meals to meet the MyPyramid goals of 5 oz. grains, 2 cups vegetables, 1.5 cups fruit, 3 cups milk, 5 oz. meat/beans after receiving family and individual instruction on use of the program. 22) Mr. and Mrs. Bloyd ask about using over-the-counter diet aids, specifically Alli (orlistat). What would you tell them? Because of Missy s young age, drug intervention is not yet necessary, because it is likely that with changes in her lifestyle and normal growth patterns of a 10 year-old, she will achieve a healthy weight as she grows. 23) Mr. and Mrs. Bloyd ask about gastric bypass surgery for Missy. What are the recommendations regarding gastric bypass surgery for the pediatric population? Gastric bypass surgery on children Missy s age is unlikely to be approved by a surgeon. Recommendations of Inge, et. al. are cited in Pediatrics, suggesting that, among other requirements, patients achieve skeletal maturity prior to surgery, which occurs around age 13 for girls (Bradley). In addition, a meta-analysis of various pediatric gastric bypass surgeries published in Annals of Surgery did cite surgeries on children as young as 9 years-old, a majority of which exhibited 4 or more cardiovascular risk factors, such as TG > 100 mg/dl, HDL-C < 90 th percentile, T-Chol > 200 mg/dl, systolic BP > 90 th percentile, and strong immediate family history of cardiovascular disease (Treadwell, et. al.). Missy does not meet either of the criteria recommended for gastric bypass surgery.

19 References American Academy of Pediatrics. About childhood obesity. Retrieved February 21, 2010, from, American Dietetic Association. (2010). Pediatric weight management guideline overview. Retrieved February 21, 2010, from, Barlow, S. E., & Dietz, W. H. (1998, September). Obesity evaluation and treatment: expert committee recommendations. Journal of the American Academy of Pediatrics. 102(3), e29. Retrieved from, Kirk, S., Scott, B. J., & Daniels, S.R. (2005, May). Pediatric obesity epidemic: treatment options. Journal of the American Dietetic Association. 105, S Retrieved from, National Heart Lung and Blood Institute. Sleep Apnea. Retrieved February 21, 2010, from Rodgers, B. M. (2004, July). Bariatric surgery for adolescents: a view from the American Pediatric Surgical Association. Journal of the American Academy of Pediatrics. 114(1) Retrieved from,