HannahChouinard

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, cream

Bologna cheese sandwich with mayo,

whole milk

Lunch
Snack

Twinkies, whole milk, Frito corn chips

Peanut butter, whole milk

Whole milk
Whole milk

Fried chicken, mashed potatoes (w/ whole

Dinner
Snack

milk), fried okra

Microwave popcorn

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

Frito Corn Chips

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.

References:

AchievingaHealthyWeightinChildren.(2009,August1).RetrievedOctober1,2015.
BariatricSurgeryQualifications.(n.d.).RetrievedOctober1,2015,from
http://www.nationwidechildrens.org/bariatricsurgeryqualifications
ChildhoodObesityFacts.(2015,August27).RetrievedOctober1,2015,from
http://www.cdc.gov/healthyschools/obesity/facts.htm
ChooseMyPlate.(n.d.).RetrievedOctober13,2015,fromhttp://www.choosemyplate.gov/
DefiningChildhoodObesity.(2015,June19).RetrievedOctober1,2015,from
http://www.cdc.gov/obesity/childhood/defining.html

Gulati,A.,Kaplan,D.,&Daniels,S.(2012).ClinicalTrackingofSeverelyObeseChildren:A
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