Case Study 1: Childhood Overweight

Sam Ballard
KNH 411
10.13.2015
I.

Understanding the 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).
Genetics
can affect body weight and body composition by influencing such factors as
appetite, taste preferences, energy intake, resting energy expenditure, the thermic
effect of food, non-exercise activity thermogenesis (NEAT), and the bodys efficiency in
storing energy (Nelms, 261-262). Children may have a
sedentary lifestyle
if their
parents either dont encourage or dont allow their kids to participate in sports or after
school activities. They may also enable sedentary behavior by purchasing video games
or other technological devices that may replace physical activity. A familys
socioeconomic status
is a large determinant of whether or not they can purchase fresh
and healthy foods. Lower socioeconomic families may be forced to purchase
prepackaged, processed, or fast food because they are cheap and convenient.
Modernization
and the reliance kids have on technology is also a major contributing
factor to childhood obesity. Modern conveniences not only promote sedentary
lifestyles in children, but they also are seen in the food industry as prepackaged,
processed foods. The prevalence of these food products has required less parents to
have skills to cook fresh foods for their children as well.
Cultural practices
influence
the types of foods consumed and the environment it is consumed in. Cultural traditions
may emphasize meal time as a social event. The length of meal time and the social
influences surrounding this event may promote overeating or the consumption of foods
that arent necessarily healthy, but are required to be eaten by custom.
Dietary intake
of sugary and high fat foods is common among children and prepackaged, processed,
and fast foods are popular among younger age groups. The values or laws of a
society
may not encourage or facilitate healthful lifestyles or behaviors.
Organizations
, such
as schools, may also contribute to childhood obesity. Even if they provide healthy
options in the cafeteria, students may not be required to consume a balanced meal or
unhealthy options may be offered in vending machines. Other organizations may
include sports teams or extra-curricular activities that provide unhealthy post-activity
snacks. A
community
may not offer safe places to play outside or businesses that allow
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kids to engage in after school activities. They may also lack resources to obtain healthy
food items, like if they were in a food desert for example. A community may also lack
advertising of healthy foods.
Interpersonal
influences may include friend groups or
family members. These individuals create a social environment and their get-togethers
may offer little option of food choices. With friends, children may feel pressured to eat
what everyone else is eating, which is usually something fast or processed.
Individually
, a child may be resistant to change their behavior because they are too
young to see the value of healthful behaviors or they may be lacking a role model. They
may see a healthy lifestyle as being too much work or more work than they are willing
to put forth.
2. Describe health consequences associated with an overweight condition. Describe how
these health consequences differ for an overweight versus an obese condition.
Being overweight or obese puts individuals at risk for developing many chronic
diseases and health issues, such as premature death, heart disease, diabetes, cancer,
breathing problems arthritis, reproductive complications, increased surgical risk, and a
decreased quality of life (Nelms, 261). The overweight or obese children and
adolescent population may be at an increased risk for chronic diseases, such as heart
disease and type 2 diabetes. Risk factors for heart disease can include hyperlipidemia
and hypertension and the prevalence of type 2 diabetes has increased dramatically in
children and adolescents (Nelms, 262). There is little difference between the health
consequences for overweight versus obese individuals. Those persons who are obese
will experience more severe and more advanced adverse health effects than those
individuals who are overweight. Obese individuals may also experience more severe
psychological issues than overweight individuals, such as anxiety and depression.
Because of the increased stress on the bodys systems, obese persons will also
experience more joint pain, breathing issues, and heart problems than individuals who
are overweight.
3. Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea. Explain the
relationship between sleep apnea and obesity.
Sleep apnea is defined as
central and/or peripheral apnea during sleep, associated
with frequent awakening and often with daytime sleepiness (MediLexicon, 2015).
Obstructive sleep apnea is defined as a disorder, first described in 1965, characterized
by recurrent interruptions of breathing during sleep due to temporary obstruction of
the airway by lax, excessively bulky, or malformed pharyngeal tissues (soft palate,
uvula, and sometimes tonsils), with resultant hypoxemia and chronic lethargy
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(MediLexicon, 2015). The apnic episodes associated with obstructive sleep apnea are
more common when lying in the supine position, or on your back. Obesity may
exacerbate obstructive sleep apnea due to fat deposition in particular sites that affect
organs of the respiratory tract. Fat deposition in the tissues surrounding the upper
airway appears to result in a smaller lumen and increased collapsibility of the upper
airway, predisposing to apnea (Romero-Corral, Caples, Lopez-Jiminez, & Somers,
2010).
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?
According to the Journal of the American Academy of Pediatrics, pediatric weight loss
should be conducted in stages. Missy is 10 years old and her BMI-for-age percentile
classifies her as being greater than the 97th percentile. The American Academy of
Pediatrics tells us that when a 6-11 year old child is in the normal 5th to 85th
percentile, they are in the prevention stage. If they enter into the overweight 85th to
94th percentile, they

Start at Prevention Plus stage. Advance to structured weight management stage after 36
mo if increasing BMI percentile or persistent medical condition. Weight goal is weight
maintenance until BMI of <85th percentile or slowing of weight gain, as indicated by
downward deflection in BMI curve (Spear et al., 2007).

If they continue to gain weight and enter into the obese 95th to 98th percentile, they
Start at Prevention Plus stage. Advance to structured weight management stage
depending on responses to treatment, age, degree of obesity, health risks, and motivation.
Advance from structured weight management stage to comprehensive multidisciplinary
intervention stage after 36 mo if not showing improvement. Weight goal is weight
maintenance until BMI of <85th percentile or gradual weight loss of
1 lb/mo. If greater
loss is noted, monitor patient for causes of excessive weight loss (Spear et al., 2007).

Once they enter the final obesity classification of greater than or equal to the 99th
percentile, they
Start at Prevention Plus stage. Advance to structured weight management stage
depending on responses to treatment, age, degree of obesity, health risks, and motivation.
Advance from structured weight management stage to comprehensive multidisciplinary
intervention stage after 36 mo if not showing improvement. After 36 mo with
comorbidity present and patient not showing improvement, it may be appropriate for
patient to receive evaluation in tertiary care center. Weight goal is weight loss not to

exceed average of 2 lb/wk. If greater loss is noted, monitor patient for causes of excessive
weight loss (Spear et al., 2007).

In summary, the four stages of weight loss include (1) Prevention Plus, which includes
appropriate food consumption, physical activity, and reduced screen time, (2)
Structured Weight Management, which offers additional support and structure to stage
1, (3) Comprehensive Multidisciplinary Intervention, which includes increased
intensity of behavioral change strategies, greater frequency of patient-provider contact,
and the specialists involved in the treatment (Spear et al., 2007), and (4) Tertiary Care
Intervention, which may include weight loss surgery or referral to a pediatric tertiary
weight management center that has access to a multidisciplinary team with expertise in
childhood obesity and that operates with a designed protocol (Spear et al., 2007).
Missy would start following the weight loss recommendations for 6-11 year olds in the
95th to 98th percentile. The overall weight loss goal for children is for them to
decrease their weight until their BMI-for-age is less than the 85th percentile. Weight
loss in overweight children may not be appropriate if the child is not full grown or if the
child has a pre-existing condition. The child should be physically and mentally able to
follow a weight loss regimen.
5. What would you recommend as the current focus for nutritional treatment of Missys
obesity?
I would recommend the current focus for nutritional treatment of Missys obesity to be
the reduction of calorie intake and the quality of foods she is consuming. This
treatment will best facilitate Missys weight loss of about 1 or 2 lbs/month. She should
accomplish these goals by reducing portion sizes, consuming less fat (less prepackaged,
processed, fast, and fried foods), and choosing foods that are less kilocalorie dense. Her
secondary focus for obesity should be physical activity.
III.
Nutrition Assessment
A. Evaluation of Weight/Body Composition
6. Overweight or obesity in adults is defined by BMI. Children and adolescents are often
times 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
professionals resources and compare/contrast their definitions for overweight conditions
among the pediatric population.
Centers for Disease Control and Prevention
Underweight
: Less than the 5th percentile
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Normal or Healthy Weight

: 5th percentile to less than 85th percentile
Overweight
: 85th to less than the 95th percentile
Obese
: 95th percentile or greater
(Centers for Disease Control and Prevention, 2015)
Academy of Nutrition and Dietetics
Underweight
: Less than 5th percentile
Normal:
5th to 85th percentile
Overweight
: 85th to 95th percentile
Obese
: More than 95th percentile
(Academy of Nutrition and Dietetics, 2014)
American Heart Association
Underweight:
Less than 5th percentile
Healthy:
Between the 5th and less than 85th percentile
Overweight:
In the 85th percentile to less than the 95th percentile
Obese:
Equal to or greater than the 95th percentile
(American Heart Association, 2013)
Although the cutoff numbers for each of the weight categories are the same, the
wording around each of them is slightly different and may cause problems when trying
to classify a child on the edge of two weight categories. For example, the CDC and AHA
use terms like less than and equal to or greater than to describe their weight
categories. The AND fails to use terms like these in describing their weight categories. If
a child was classified as being in the 85th percentile, they may be placed in different
weight categories depending on the professional resource used to classify them. The
CDC and AHA would classify this child as overweight whereas the AND wouldnt know
whether to classify them as normal or overweight because both categories include
the 85th percentile and lack phrases such as less than or greater than or equal to.
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?
Missys BMI-for-age places here in the >97th BMI percentile. The CDC, AND, and the
AHA would classify Missys weight status as obese.
B. Calculation of Nutrient Requirements
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8. If possible, RMR should be measured by indirect calorimetry. Identify two methods for
determining Missys energy requirements other than indirect calorimetry and then use
them to calculate Missys energy requirements.
Mifflin-St. Jeor
[10 x wt (kg) + 6.25 x ht (cm) - 5 x age (yrs) - 161] x PAL
[10 x (115 lbs./2.2 kg) + 6.25 x (57 in. x 2.54 cm) - 5 x 10 - 161] x 1.5
[10 x 52.3 + 6.25 x 144.78 - 5 x 10 - 161] x 1.5
[523 + 904.875 - 50 -161] x 1.5
[1,216.875] x 1.5
1,825 kcal/day
Harris Benedict
[655 + (9.56 x wt (kg)) + (1.85 x ht (cm)) - (4.68 x age (yrs))] x PAL
[655 + (9.56 x (115 lbs./2.2 kg)) + (1.85 x (57 in. x 2.54 cm)) - (4.68 x 10)] x 1.5
[655 + (9.56 x 52.3) + (1.85 x 144.78) - 46.8] x 1.5
[655 + 500 + 267.8 - 46.8] x 1.5
[1,376] x 1.5
2,064 kcal/day
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 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:
Breakfast burritos
Bologna and cheese sandwich
Fried foods (chicken and okra)
Added milk and butter to mashed potatoes
Whole milk
Twinkies
Increased kilocalorie-dense beverages:
Whole milk
Sweet tea
Coca-Cola
Apple juice
6

Cream and sugar added to coffee

Meal
Breakfast

Lunch

After-school
snack

Dinner

Snack

Food Item

kcal

2 breakfast burritos

613

8 oz whole milk

149

4 oz apple juice

57

6 oz coffee

c cream

79

2 tsp sugar

33

2 bologna and cheese sandwiches

695

1 tbsp mayonnaise

99

1 oz pkg Frito corn chips

145

2 Twinkies

299

8 oz whole milk

149

2 slices enriched bread

138

2 tbsp crunchy peanut butter

190

2 tbsp grape jelly

101

12 oz whole milk

223

2 fried chicken legs

387

1 fried chicken thigh

254

1 c mashed potatoes with milk and

butter

212

1 c fried okra

177

20 oz sweet tea

118

3 c microwave popcorn

250

12 oz Coca-Cola

136

Total kcal
933

1,387

652

1,148

386

24-hour recall total kcal:

4,506

www.supertracker.usda.gov
Macronutrient

Kilocalories

Percentage of
Kilocalories

Carbohydrates

451g x 4kcal/g = 1,804

40%

Fat

N/A

46%

Protein

166g x 4kcal/g = 664

15%

Fluids

946

21%

**Kilocalories from fat were not provided in grams by Supertracker, but % fat was.
10. Increased fruit and vegetable intake is associated with decreased risk of overweight.
Using Missys usual intake, is Missys fruit and vegetable intake adequate?
According to Missys 24-hour recall, her fruit and vegetable intake is extremely
inadequate and almost absent. Apple juice and grape jelly are the only food items that
even slightly resemble fruit intake and they are both higher in sugar than fresh fruit
would be. Grape jelly would be considered more of a sweet sugar item than it would a
fruit! For vegetable intake, Missy consumed fried okra and mashed potatoes. The okra
being fried and the mashed potatoes containing butter and whole milk added
unnecessary fat intake. Because Missy is not eating fresh fruits and vegetables, she is
not benefiting from the vitamin, minerals, and fiber provided by them. This lack of
intake of two main food groups could be a major contributing factor to her obese weight
classification.
11. Use the MyPyramid Plan online tool (available from
http://www.mypyramid.gov/
;
click on MyPyramid Plan) to generate a personalized MyPyramid for Missy. Using this
eating pattern, plan a 1-day menu for Missy.
Personalized MyPlate Eating Pattern
Food Group

Recommended Servings

Grains

6 oz/day

Vegetables

2 c/day

Fruit

2 c/day

Protein

5 oz/day

Dairy

3 c/day

Total Calories

2,000 kcal

https://www.supertracker.usda.gov/myplan.aspx
Sample 1-Day Meal Plan
Breakfast
1 fried egg w/butter
8 oz 2% milk
1 slice toast
1 tbsp butter
____________________________________________________________
Snack
1 c mixed fruit
8 oz water
____________________________________________________________
Lunch
2 oz thin sliced turkey breast
2 slices whole wheat bread
1 slice cheese
1 tbsp mayonnaise
1 c baby carrots
8 oz 2% milk
___________________________________________________________
After-school
10 whole wheat crackers
snack
2 tbsp peanut butter
1 medium apple
8 oz sweet tea
__________________________________________________________
Dinner
3 oz grilled chicken breast
c green beans
c roasted potatoes
1 small piece of cornbread
8 oz 2% milk
12. Now enter and assess the 1-day menu you planned for Missy using the MyPyramid
Tracker online online tool (
http://www.mypyramidtracker.gov/
). Does your menu meet
macro- and micronutrient recommendations for Missy.
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Sample 1-Day Meal Plan

Meal
Breakfast

Snack

Lunch

After-school snack

Dinner

Food Item

kcal

1 fried egg w/
butter

92

8 oz 2% milk

122

1 slice toast

69

1 tbsp butter

102

1 c mixed fruit

93

8 oz water

2 oz thin sliced
turkey breast

59

2 slices of whole
wheat bread

138

1 slice cheese

65

1 tbsp mayonnaise

99

1 c baby carrots

52

8 oz 2% milk

122

10 whole wheat
crackers

162

2 tbsp peanut
butter

195

1 medium apple

72

8 oz sweet tea

47

3 oz grilled chicken
breast

138

c green beans

33

c roasted
potatoes

142

Total kcal
385

93

535

476

602

10

1 small piece of
cornbread

167

8 oz 2% milk

122

Sample 1-day meal total kcal:

2,091 kcal

www.supertracker.usda.gov
Macronutrient

Kilocalories

Percentage of
Kilocalories

Carbohydrates

228g x 4kcal/g = 912

44%

Fat

N/A

38%

Protein

106g x 4 kcal/g = 424

20%

Fluids

413

20%

**Kilocalories from fat were not provided in grams by Supertracker, but % fat was.
D. Clinical Domain
13. Why did Dr. Null order a lipid profile and a blood glucose test?
Dr. Null most likely ordered a lipid profile because Missys obesity, high calorie and high
fat containing diet recall, and reported lack of physical activity put her at risk for
dyslipidemia. He will want to closely monitor Missys total cholesterol, HDL, LDL, and
triglyceride levels in order to prevent further disease, such as atherosclerosis or
coronary heart disease. He most likely ordered a blood glucose test because of Missys
family history of diabetes. Missys obesity also puts her at an increased risk for
hyperglycemia and diabetes.
14. What lipid and glucose levels are considered to be abnormal for the pediatric
population?
According to the normal values reported on Missys medical chart, the normal lipid and
glucose levels for the pediatric population are:
Lab Value

Normal Value

Total Cholesterol

120-199 mg/dL
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HDL-C

>55 mg/dL (women)

LDL

<130 mg/dL

VLDL

7-32 mg/dL

LDL/HDL ratio

<3.22 (women)

Apo A

101-199 mg/dL (women)

Apo B

60-126 mg/dL (women)

Triglycerides

33-135 mg/dL (women)

Glucose

70-110 mg/dL

HbA
1c

3.9-5.2 %

**Values above or below these normal values would be considered abnormal for the
pediatric population.
15. Evaluate Missys lab results.
Abnormal Lab

Normal Value

Abnormal Value

Low or High

Ammonia (NH
) (umol/L)
3

9-33

Low

HDL-C (mg/dL)

>55

50

Low

HbA
(%)
1c

3.9-5.2

5.5

High

Missys ammonia level is only slightly lower than the normal value, so I wouldnt
assume that something is wrong. Low ammonia levels can usually be attributed to
kidneys not removing waste as they should (University of Rochester Medical Center,
2015) or some types of hypertension (American Association for Clinical Chemistry,
2015). Missys low HDL-C level is most likely due to her unhealthy fat intake. Choosing
healthier fat sources, losing weight, and becoming more physically active are all ways to
increase HDL-C levels and lower LDL levels (Mayo Clinic, 2015). Missys HbA
level is
1c
slightly high. This test shows average glucose levels over the past three months and is
a
usually used for diabetes patients (MedlinePlus
, 2015). This result means that Missys
average glucose levels over the past three months have been slightly elevated, probably
due to her excessive calorie and oral intake consumption. Her family history indicates
that her mother and grandmother had possible gestational diabetes and type 2 diabetes
12

mellitus. This risk of diabetes may be of concern to Missy and her HbA
level should
1c
continue to 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 diets?
I would look to assess what time Missy and her family eat their meals, their meal
preparation methods (i.e. added sodium or fats), how often they eat out, the types of
foods Missys parents eat as her lifestyle role models, if they eat together as a family,
and if their lifestyles include any forms of physical activity.
17. What aspects of Missys lifestyle place her at increased risk for overweight?
Because of her young age, Missy does not engage in as many negative lifestyle factors
that are affecting her obesity as she would if she were an adult. Missy has a very low
physical activity level and consumes an extreme excess of calories each day. Her
elementary school does not give her the opportunity to be active at school because they
have discontinued physical education and when she isnt in school, she plays video
games and reads books. An analysis of Missys 24-hour recall reveals that she
consumed 4,506 kcal that day, which is more than double her recommended calorie
intake of about 2,000 kcal/day.
18. You talk with Missy and her parents. They are all friendly and cooperative. Missys
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?
I would explain to them that it is good that Missy snacks between meals, as long as the
snacks are healthy, such as carrot sticks, apple slices or whole wheat crackers with
peanut butter. Having smaller, more frequent meals will allow Missys metabolism to
continually be working and hopefully allow her to start burning more calories to lose
weight. I would also tell them that it is not in their childs best interest to use desserts
as a reward for exercise. If they insisted on using rewards for exercise, they should
focus on using non-food reinforcements.
19. Identify one specific physical activity recommendation for Missy.
The Physical Activity Guidelines for Americans, issued by the U.S. Department of
Health and Human Services, recommend that children and adolescents aged 6-17 years
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should have 60 minutes (1 hour) or more of physical activity each day (CDC, 2015).
One specific physical activity recommendation for Missy would be to replace 60
minutes of playing video games with an activity that she likes to do outside, such as
riding a bike, going on a walk, or playing with friends. She can split up these 60 minutes
however she would like. For example, she could have four 15 minute physical activity
breaks, two 30 minutes breaks, or one 60 minute break.
IV.

Nutrition Diagnosis
20. Select two high-priority nutrition problems and complete PES statements for each.
A.) Excessive energy intake (NI-1.3) related to food-and nutrition-related knowledge
deficit concerning energy intake as evidenced by a BMI >97th percentile and a 24-hour
recall indicating an intake of about 4,500 kcal/day, more than double the estimated
energy needs of about 2,000 kcal per day.
B.) Excessive oral intake (NI-2.2) related to food-and nutrient-related knowledge deficit
concerning appropriate oral food/beverage intake as evidenced by a 24-hour recall
indicating an intake high-caloric density foods/beverages at meals and/or snacks.
C.) Physical inactivity (NB-2.1) related to food and nutrition related knowledge deficit
concerning health benefits of physical activity as evidenced by a BMI >97th percentile,
lack of physical activity access in school, and large amounts of sedentary activities (i.e.
video games and reading books).

V.

Nutrition Monitoring and Evaluation

21. For each PES statement written, establish an ideal goal (based on signs and symptoms)
and an appropriate intervention (based on etiology).
A.) An ideal goal for reducing Missys excessive energy intake would be to reduce her
daily calorie intake by about half. Missy would ideally consume only around 2,000
calories rather than the 4,500 calories she consumed in her 24-hour recall. This will
result in a lower BMI percentile range. This weight reduction would occur in stages so
missy would progress from >97th percentile, to the 85th to 95th percentile, and then
finally to the 5th to 85th percentile range. In order to reduce Missys energy intake to
around 2,000 calories per day, her and her parents would need to attend nutrition
education sessions to learn about appropriate serving sizes, less calorically dense foods,
and proper meal preparation methods.

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B.) An ideal goal for reducing Missys excessive oral intake would be very similar to her
goal for reducing her excessive energy intake. Missy would want to reduce the amount
of food and beverages she consumes as well as her portion sizes. An appropriate
intervention would be the same as that for reducing her excessive energy intake. Missy
and her parents would attend nutrition education sessions to learn about appropriate
eating patterns and serving sizes.
C.) Although there is little Missy or her parents can do about physical activity in school,
Missys goal for after school physical activity should be at least 60 minutes a day. She
should try to find physical activities to replace an hours worth of playing video games
and reading each day. During the nutrition education sessions to reduce Missys
excessive caloric and oral intake, she should also be educated on the importance and
benefits of physical activity in addition to a healthy diet. She should be provided with
suggested exercises or fun activities to do on her own or with friends and family after
school.
22. Mr. and Mrs. Bloyd ask about using over-the-counter diet aids, specifically Alli
(orlistat). What would you tell them?
Orlistat is a lipase inhibitor that prevents some of the fat in foods eaten from being
absorbed in the intestines. The unabsorbed fat is passed in the stool. This medication is
intended for weight loss and is used with an individualized low-calorie, low-fat diet and
exercise program. It is commonly used in patients with high blood pressure, diabetes,
high cholesterol, or heart disease. Orlistat is taken by mouth three times daily with
every meal that contains fat. It does not need to be taken with meals that do not contain
fat. When taking this diet aid, it is recommended that patients evenly divide their daily
amount of fat, carbohydrates, and protein between three meals, so snacks may not be
recommended with this medication. Missy will have to avoid foods that contain more
than 30% fat, eat lean protein sources of 2 to 3 ounces per serving, cook with less fat,
consume low- or reduced-fat dairy sources, and avoid prepackaged, processed, and fast
foods. She would also need to take vitamin A, D, E, K, and beta-carotene supplements (a
multivitamin) because the drug blocks the absorption of these fat-soluble vitamins and
beta-carotene. Side effects of Orlistat can include gas, urgent bowel movements, loose
stools, oily or fatty stools, rectal pain or discomfort, abdominal pain, headaches, anxiety,
nausea, vomiting, loss of appetite, excessive tiredness, weakness, and difficulty
b
breathing or swallowing to name a few (MedlinePlus
, 2015).
23. Mr. and Mrs. Bloyd ask about gastric bypass surgery for Missy. What are the
recommendations regarding gastric bypass surgery for the pediatric population?
15

There are many guidelines for children in regards to weight-loss surgery. The general
guidelines include for the child to have a BMI 35 or higher and a serious health
condition related to obesity, such as diabetes, sleep apnea, or severe liver inflammation;
have a BMI of 40 or higher and a less serious health condition related to obesity, such as
high blood pressure, high cholesterol, mild sleep apnea, or depression; the child has not
been able to lose weight while on a physician prescribed diet and exercise program; the
teenager should be finished growing (13 years or older for girls); parents and teen
understand and are willing to follow necessary lifestyle changes post-surgery; and the
teen has not used any illegal substances (alcohol or drugs) in the past 12 months
c
(MedlinePlus
, 2015). According to these guidelines, Missy would not be a candidate for
gastric bypass surgery at this time. She would have to wait three more years until she
turns 13 or becomes full grown to even be considered for the surgery. Missy would also
have to be greater than the 99th BMI-for-age percentile to be considered for gastric
bypass surgery at this time and she is only greater than the 97th BMI-for-age percentile.
IV. Nutrition
24. When should the next counseling session with Missy be scheduled?
The next counseling session with Missy could be scheduled for the following week. This
will give Missy and her family enough time to adjust to the new diet and exercise
schedule and figure out what works and doesnt work for their lifestyles. When they
come back for the counseling session, they will be able to express their successes and
failures and recommend adjustments that would assist in their diet compliance. A
counseling session that occurs too soon after the initial session may not provide a
Dietitian with the appropriate amount of feedback about the clients progress because
the client didnt get an opportunity to attempt to incorporate it into their daily lives and
typical week. If Missy seems to be complying with the diet and exercise regimen after
the first couple of weeks, the counseling sessions could be made for every two weeks.
On the other hand, if Missy seems to be struggling with the prescribed diet and exercise
regimen, the counseling sessions may need to continue to be scheduled once a week or
for more than once a week. The more progress Missy makes, the farther apart her
counseling sessions can be and vice versa, but it is important that she continue to attend
them.
25. Should her parents be included? Why or why not?
Missys parents should be included in her counseling sessions unless otherwise
requested by the family. Because Missy in an adolescent, her lifestyle is still strongly
16

influenced by her parents. Her parents control what foods are stored in the house, what
gets served at mealtimes, how foods are prepared, what Missy can or cant do as far as
physical activity (i.e. join a sports team, play outside with friends, own a bike to ride),
and they are role models that Missy will be looking to for food and physical activity
habits. The nutrition counseling and education sessions are just as much for Missys
parents as they are for Missy herself. Their involvement may also help Missy to feel
supported, encouraged, and safe.
26. What would you assess during this follow-up counseling session?
During the follow-up counseling session, I would assess Missys usual intake and
24-hour recall once again. I would want to see that her calorie intake had reduced to a
total daily calorie intake closer to her recommended 2,000 kcal diet. It would not have
to be exactly at this value yet, but I would like to see it trending towards 2,000 kcal/day.
The foods she is consuming should be lower in fat, prepared with less fat, prepared
using fresh ingredients, not all prepackaged, processed, or fast foods, and should be
smaller portion sizes. I would also want to see if she has started incorporating physical
activity into her daily routine to complement her new diet. Her diet and physical
activity would be tracked in a food and activity journal that would be assessed and
discussed at each counseling session. I would like to continue to monitor her HbA
1c
value to watch for the possibility of diabetes and I would like to see her lipid profile
return to normal (higher HDL-C levels). Her height, weight, blood pressure, and
BMI-for-age percentile would continue to be assessed at each counseling session as
well. These values could fluctuate often because of her young age.

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