Case Study #1: Pediatrics, Amy Torget Assessment Food/Nutrition Related History Per chart: pt has a very good appetite with consumption of a wide variety of foods 24 hour recall: excessive caloric and fat intake (~4500 kcal, ~250 g fat), inadequate intake of fruit and vegetables, excessive intake of processed foods, excessive intake of calorically dense beverages Food purchase/preparation: parents Estimated needs: ~1800 kcal (TEE for overweight females ages 3-18, PA =1.0, sedentary), ~52g- 158 g pro (1.0 g/kg bw and 35% of total kcals) Anthropometric Measurements Ht: 57 inches (144.8 cm) Wt: 115 lbs (52.3 kg) BMI: 25.2, BMI for age: >95 th percentile, obese Growth charts: weight for age: >95 th percentile height for age: ~82 nd percentile Biochemical Data, Medical Tests, and Procedures WNL except: HbA1c of 5.5% (H), HDL- C of 50 (L) Nutrition- Focused Physical Findings Somewhat tired and irritable, slight rash in skin folds Skin: reduced capillary refill (approximately 2 seconds) Abdomen: obese Client History 10 yo female with obstructive sleep apnea secondary to obesity and physical inactivity, overweight since birth, family h/o type 2 DM and possible gestational diabetes (mother and grandmother) Parents report sleep disturbances in daughter for the past year and deficits in attention span at school: o sleeping with mouth open, cessation of breathing for at least 10 seconds (per episode), snoring, restlessness during sleep, enuresis, and morning headaches Diagnosis 1) Excessive energy intake related to frequent consumption of large portions of high- fat and convenience foods as evidenced by 24- hour recall, BMI >95 th percentile, and recent diagnosis of sleep apnea.
2) Physical inactivity related to lack of role models as evidenced by BMI >95 th percentile, large amounts of sedentary activities such as reading and playing video games, and elementary school discontinuing PE classes. Intervention Food/Nutrient Delivery Nutrition prescription: 1. Gradual reduction of portion sizes and high fat foods in diet (<30% of calories from fat) 2. 30 minutes of moderate physical activity on most days of the week, starting with 15 minutes of accumulated activity 2 to 3 times/week Nutrition Education Initial/Brief Nutrition Education: Purpose of nutrition education is to assess pt/family concerns related to dietary prescription. o Goal: To create a patient and family- centered rationale for dietary modifications resulting in a motivation to change lifestyle. Comprehensive Nutrition Education: Provide patient and family with written and verbal instructions on proper portion sizes using MyPlate and the accompanying recommended serving sizes/day from each food group (1.5 cups fruit, 2 cups vegetables, 5 ounces of grains- half of which should be whole, 5 ounces of protein, 3 cups of low- fat dairy). o Goal: increased awareness of proper portion sizes, increased fruit and vegetable intake Nutrition Counseling: Cognitive-Behavioral Theory: Brainstorm with family and set goals on how to gradually replace high fat and convenience foods with lower calorie and lower fat foods such as fruits, vegetables, whole grains, and 1% or non- fat milk. Brainstorm/set goals with family and patient on increasing physical activity levels (playing Wii video games, taking a family walk after dinner, going to the park). o Goal: decreased fat and calorie intake, decreased intake of processed foods, increased weekly physical activity
Guidelines and Summary Pediatric Weight Management: Determination of Total Energy Expenditure: If possible, RMR should be measured to determine energy expenditure. If RMR is not measurable, then the TEE equations for overweight and obese youth in the 2005 U.S. Institutes of Medicine, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients), should be used. For this particular patient, RMR was not measured. Therefore, the TEE equation provides the most reliable estimate of calorie intake needed for weight maintenance. The AAP report does not specifically mention the TEE equation as a method for establishing calorie needs, but instead suggests consuming a diet with balanced macronutrients as recommended by the Dietary Reference Intakes. Pediatric Weight Management: Nutrition Prescription in Treatment of Obesity: An individualized nutrition prescription devised as part of the intervention has been shown to provide more consistent improvements in weight status in children and adolescents than interventions without nutrition prescriptions. Through analysis of this patient s 24- hour recall, it can be concluded that her calorie and fat intakes are excessive. A nutrition prescription may help the family understand that the patient s usual dietary intakes are significantly greater than her actual needs. Also, it will provide the family with calorie and fat intakes for Missy to aim for. The AAP recommendations for nutrition prescriptions follow the EAL guidelines very closely. The AAP suggests planning a diet with balanced macronutrients in proportions consistent to the Dietary Reference Intake recommendations. Pediatric Weight Management: Physical Activity: Research indicates that promoting increased physical activity as part of a comprehensive nutrition intervention results in considerable improvements in weight and body composition in children and adolescents. This patient leads a sedentary lifestyle du to her elementary school eliminating PE, her time spent playing video games, and possible lack of a role model who does regular physical activity. Focusing on ways to gradually increase physical activity levels may result in the
patient achieving a healthier BMI and maintaining a healthy weight throughout her life. The AAP also makes the recommendation that overweight and obese children should be physically active to promote weight loss. The AAP recommendation gets more specific than the EAL, suggesting that children get greater than or equal to 1 hour of physical activity per day. Pediatric Weight Management: Family Participation: Including parents or caregivers in the counseling and education portion of weight management programs (for six to twelve year olds) is linked to short and long- term improvements in weight. Some research even suggests that a lack of parental participation is completely ineffective in promoting weight management in this age group. In a 12 month randomized, prospective trial conducted by Golan, Weizman, Apter, and Fainaru (1998), researchers found that treatment of childhood obesity with inclusion of the family not only results in increased weight loss for the children, but also has the potential for weight loss in the parents. This patient, like most ten year olds, relies on her parents for food purchasing and preparation. It would be difficult for Missy to incorporate healthy foods into her diet if her parents weren t also provided education on means do this. Missy s family needs to be an integral part of her lifestyle changes by attending the counseling sessions and setting a healthy example through food purchase, food preparation, and physical activity. The AAP guidelines also make the recommendation for including the child s family in the counseling process. The AAP stresses that parents serve as role models, authority figures, and behavioralists to mold their children s eating and activity habits. Furthermore, dietitians have the ability to indirectly influence the children s habits through the teaching and motivation of parents. Pediatric Weight Management: Behavioral Strategies: The utilization of behavioral therapy strategies in pediatric weight management programs is linked to weight status and body composition improvements. In a randomized controlled trial conducted by Flodmark, Ohlsson, Ryden, and Sveger (1993), children receiving goal setting and cognitive restructuring focused treatment had a lower BMI and greater improvement in adiposity than children receiving interventions without a behavioral component. Using behavioral strategies such as cognitive restructuring and goal setting would greatly benefit both Missy
and her parents. The patient and her parents need to be taught to focus on the successes of achieving a small goal instead of failures to adhere to the plan. Gradual, easily achievable goals should be developed with input from both the parents and the patient. The AAP, like the EAL guidelines, suggests that cognitive restructuring is a vital component of obesity management in children. Imperfect adherence to the plan does not equal failure. Patient and family thoughts must be restructured to avoid exaggerating negative consequences of a single event (AAP, 2007).
References Academy of Nutrition and Dietetics Evidence Analysis Library. " Pediatric Weight Management Guidelines", Accessed 28 January 2012, https://sakai.ohsu.edu/access/content/group/nutn- 511-0- 20121- W12/Neonatal_Pediatric%20files/Pediatric%20case%20files/EAL_Ped%20Wt%20Mgmt.p df. Barlow, Sarah E. Official Journal of the American Academy of Pediatrics. Expert Committee Recommendations Regarding the Prevention, Assesment, and Treatment of Child and Adolescent Overwight and Obesity: Summary Report. Accessed27 January 2007. http://pediatrics.aappublications.org/content/120/supplement_4/s164.full.html Berkey CS, Rockett HRH, Field AE, Gillman MW, Frazier AL, Camargo CA, Colditz GA. Activity, dietary intake, and weight changes in a longitudinal study of preadolescent and adolescent boys and girls. Pediatrics 2000; 105: 1-9. "CDC Growth Charts." Centers for Disease Control and Prevention, National Center for Health Statistics, 09 September 2010. Web. Accessed 27 January 2012. http://www.cdc.gov/growthcharts/cdc_charts.htm. Escott- Stump, Sylvia. Nutrition and Diagnosis Related Care 6th Ed. Lippincott Williams & Wilkins 2008. pp 184. Flodmark, CE, Ohlsson T, Ryden O, Sveger T. Prevention of progression to severe obesity in group of obese schoolchildren treated with family therapy. Pediatrics 1993: 91: pp 880-84. Golan M, Weizman A, Apter A, Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity. Am J Clin Nutr 1998;67: pp 1130-1135. Mahan, L. K., and S. Escott- Stump. Krause's Food & Nutrition Therapy. 12. St. Louis: Saunders Elsevier, 2008. pp 556-557. National Research Council. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Washington, DC: The National Academies Press, 2005. 1. Print.