Answer Guide for Medical Nutrition Therapy: A Case Study ...

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Pediatric Weight Management

Case Questions

Submitted by

Michaela M. Phillips

In fulfillment of partial requirements of NUTR 504

Professor Eileen Fitzpatrick

Sage NCP Form Student Name: Michaela M. Phillips

Case: #1, Pediatric Weight Management

|Patient: Jamey |Referred for: Nutrition Counseling for weight management |

|NUTRITION ASSESSMENT |

|Food and Nutrition Related History: Low physical activity level (FH-7.3); 24hr recall indicates high consumption of sugar added beverages and high |

|carbohydrate-high fat snacks. Actual calorie intake (4493) exceeded recommended intake using Diet Analysis Plus (1726) by 2767 calories. |

|Anthropometric Measurements |

|Age: 10 |Gender |Ht: |Wt: 115 lbs |BMI: |

| |Female |57 in |Wt Hx: Overweight since birth |24.88; above 97th percentile; obese |

|Biomedical Data, Medical Tests & Procedures |

|Labs/Date |

|Pertinent Medications/Supplements/Herbs: |

|Flintstones vitamin daily. |

|Skin status: □ Intact □ Pressure Ulcer/Non-healing wound; Comments: Warm, dry skin with slight rash in skin folds. |

|Patient/Client/Family Medical/Health/CAM History: Mother and grandmother had possible gestational diabetes and type 2 Diabetes Mellitus. |

|Estimated Nutritional Needs Based on Comparative Standards: |

|Calories |Protein |Fluid |

| | | |

|1789.5 Kcal per day for weight maintenance |.95 g/Kg or 50 g per day |1.8 L (1 mL per Kcal) |

|(REE calculated using Mifflin-St. Jeor = 1383 Kcal x 1 | | |

|(sedentary)) | | |

|(TEE calculated using IOM DRI for overweight girls = 1789 | | |

|Kcal) | | |

|Current Diet Order |Feeding Ability |Oral Problems |Intake |

| |x Independent |□ Chewing Problem |x Good (> 75%) |

|None |□ Limited Assistance |□ Swallowing Problem |□ Fair (approx. 50%) |

| |□ Extensive/Total Assistance |□ Mouth Pain |□ Poor (21 or|

| | | | |22 kg/m2) |

|6-11 |Maintain weight velocity |Decrease weight velocity or weight |Weight maintenance or gradual |Weight loss not to exceed an |

| | |maintenance. |loss (1lb/mo) |average of 2 lb/wk |

|12-18 |Maintain weight velocity. After |Decrease weight velocity or weight |Weight loss not to exceed an |Weight loss not to exceed an |

| |linear growth complete, maintain |maintenance. |average of 2 lb/wk |average of 2 lb/wk |

| |weight | | | |

Pediatrics December 2007 vol. 120 no. Supplement 4 S164-S192 doi: 10.1542/peds.2007-2329

6. Under what circumstances might weight loss in overweight children not be appropriate? Weight loss would not be appropriate for children who are less than the 95th percentile for BMI. It would not be appropriate in certain disease cases or if someone is pregnant.

7. What would you recommend as the current focus for nutritional treatment of Jamey’s obesity? She should initiate gradual weight loss of 1lb per month and focus on reducing empty calories in her diet; she should replace unhealthy snacks with healthier snack options.

8. Evaluate Jamey’s weight using the CDC growth charts provided (p. 8): What is Jamey’s BMI percentile? How is her weight status classified? Use the growth chart to determine Jamey’s optimal weight for height and age. Her BMI percentile is 97% and she is obese. Optimal weight for her age is about 75lbs.

9. Two methods for determining Jamey’s energy requirements other than indirect calorimetry:

Mifflin St. Jeor REE: 10(wt = 52.3Kg) + 6.25 (ht = 144.78 cm) – 5 (age=10) + 5 = 1382.9 Kcals (PA level of 1 time 1382.9 = 1382.9 Kcals)

Institute of Medicine equation for weight maintenance in overweight girls:

TEE = 389 – (41.2 × age [y]) + PA × (15.0 × weight [kg] + 701.6 × height [m])

389-(41.2 * 10) + 1* (15.0 * 52.3 + 701.6 * 1.45) = 1789 kcals

10. Dietary factors associated with increased risk of overweight are increased dietary fat intake and increased calorie-dense beverages. Identify foods from Jamey’s diet recall that fit these criteria: Sugar in coffee, Frito corn chips; Mayonnaise on the sandwich; Twinkies; Fried chicken; butter in mashed potatoes; fried okra; sweet tea; coca cola; and possibly the popcorn if it is buttered.

11. Percent of kcal from each macronutrient and the percent of kcal provided by fluids for Jamey’s 24-hour recall.

[pic]

|Item Name |Kcal(kcal) |% total cal |

|Milk, Whole 3.3% |148.84 |  |

|Juice, Apple, Unsweetened, Canned |57.04 |  |

|Coffee, Brewed |1.7775 |  |

|Cream, Half and Half |78.65 |  |

|COCA-COLA Coke Soda |210 |  |

|Milk, Whole 3.3% |148.84 |  |

|NESTEA Iced Tea Drink, Sweetened |157.5 |  |

|Milk, Whole 3.3% |223.26 |  |

|  |1025.91 |23% |

12. Increased fruit and vegetable intake is associated with decreased risk of overweight. What foods in Jamey’s diet fall into these categories? Just the 4oz apple juice, 2 tbsp grape jelly, and 1 c. fried okra.

15. Why did Dr. Lambert order a lipid profile and blood glucose tests? What lipid and glucose levels are considered altered (i.e., outside of normal limits) for the pediatric population? Evaluate Jamey’s lab results. There is a risk that she could have metabolic syndrome or diabetes. The low HDL of 50 mg/dL (ref: >50) could be raised by incorporating physical activity daily.

16. What behaviors associated with increased risk of overweight would you look for when assessing Jamey’s and her family’s diets? What aspects of Jamey’s lifestyle place her at increased risk for overweight?

Factors that place people at risk of being overweight are genetic, environmental and diet based. The fact that she has a sedentary lifestyle and that she has a poor diet are two major factors in Jamey’s obesity. The fact that the school budget cut physical activities out is another big environmental factor. Family meals and physical activity are two major aspects of Jamey’s life that place her at increased risk for being overweight.

17. You talk with Jamey and her parents, who are friendly and cooperative. Jamey’s mother asks if it would help for them to not let Jamey snack between meals and to reward her with dessert when she exercises. What would you tell them? Generally, studies have shown that rewarding with dessert tends to override hunger/satiety cues and promotes overeating to get the reward.

18. Identify one specific physical activity recommendation for Jamey. I would recommend 30 minutes of exercise per day such as brisk walking as long as a physician has permitted it.

19. Select two nutrition problems and complete PES statements for each.

|P (problem): NI-1.5 Excessive Energy Intake |E (Etiology): Lack of understanding of energy intake |S (Signs & Symptoms): BMI of 24.88, which is above |

|related to: |requirements. as evidenced by: |97th percentile; HbA1C of 5.5%; HDL 50 mg/dL. |

|P (problem): NB-1.1 Food and Nutrition related |E (Etiology): Lack of prior exposure to accurate |S (Signs & Symptoms): Excessive intake of energy. |

|knowledge deficit related to: |nutrition-related information as evidenced by: |Calories exceed requirements by 2700 Kcals. |

20. For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on etiology).

For problem NI-1.5, the recommendation would be to adjust the diet to 2000 calories per day and maintain nutrient density; increase aerobic physical activity to 30 minutes per day pending physician approval.

ND-1.1; ND-1.2; ND-1.3; Meals and snacks

Weight loss of 1 lb per month; In 4-6 weeks, a loss of 4-6 lbs until BMI at or below the 85th percentile is achieved.

Reduce empty calories, high sugar and high fat foods in the diet; limit fried foods to 8oz per week and select other cooking methods the rest of the week.

Reduce sugar sweetened beverages to one per day; have 4oz juice per day.

Switch to healthy lower calorie snack options. Consider raw fruits or vegetables with low calorie dips.

Switch to reduced fat or skim milk instead of whole milk.

For problem NB-1.1, the instruction would happen on the spot because studies have shown that, if clients are handed information and it is not discussed, the likelihood of them reading it is not very high.

21. Mr. and Mrs. Whitmer ask about using over-the-counter diet aids, specifically Alli (orlistat). What would you tell them?

This drug is not approved for children less than 12 years old (PEDIATRICS Volume 120, Supplement 4, December 2007, pg. S277, downloaded from pediatrics. by guest on March 9, 2014).

22. Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey. Using the EAL, what are the recommendations regarding gastric bypass surgery for the pediatric population?

BMI of 40 kg/m 2 with a medical condition or 50 kg/m2; physical maturity (generally 13 years of age for girls and

15 years of age for boys) (PEDIATRICS Volume 120, Supplement 4, December 2007 pg S185, retrieved March 9, 2014 from pediatrics. on March 9, 2014).

23. What is the optimal length of weight management therapy for Jamey? It is at least 3 months per the EAL. The length of therapy depends on many factors including maintaining the diet plan and whether or not she has any growth. Because her ideal weight for her age and stature is around 75 pounds, it could take over a year for her weight to come down and her to grow into an ideal weight.

24. Should her parents be included? Why or why not? The parents should definitely be included because they have a major role in her nutrition. If they model appropriate nutrition, it will make it easier for Jamey to stick to her plan. The parents are responsible for offering healthy options and Jamey is responsible to choose how much to eat.

25. What would you assess during this follow-up counseling session? Food intake, physical activity records, BMI and weight would be reassessed during the follow up session to see if any progress was made or determine the reasons why progress was not made and see if there are any other courses of action for Jamey and her parents. If there are any gaps in understanding directions, more information would be given out.

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