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Weight Management Case StudyMichelle HoffmanKNH 411Current 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 (sedimentary lifestyle, socioeconomic status, modernization, culture, and diet intake); and global (society, community, organizational, interpersonal, and individual).Childhood obesity has become a prevalent topic in today’s society because it has turned into an epidemic in developed nations. In association with childhood obesity, there are several related health complications that twenty years ago, would never have occurred in a child/young adult (Type II diabetes and pre-hypertension symptoms for example). To begin understanding the cause of childhood obesity, one must look at the research related to it. In terms of biological factors, there have been several epidemiological studies shown that genetics may play a role in childhood obesity. Genes may play a role in how our body’s capture, store, and release fat (metabolic rate). The “thrifty genotype” reveals the possibility that our bodies favor the accumulation of fat in certain environments (developed countries are surrounded by food). This would cause us to overeat, be less active, and have an enlarged capacity to store body fat. One may inherit a certain body fat distribution as well, and distribution around the abdomen is associated with an increased risk for chronic disease. There have also been studies that reveal the strong likelihood of being overweight or obese if there is a family history. There are several behavioral and environmental risk factors to consider as well in the development of childhood obesity. Children are becoming more sedentary than they once were, and a major reason for this is the advancement of technology. Instead of playing sports outside, children are spending up to 7 hours watching television, playing video games, computer games, as well as using their Smartphones. With a decrease in physical activity, there is less energy being expended and children are at a higher risk for obesity. Children are also more exposed to fast food than ever, and with this fast-paced life that developed countries have, the convenience of a drive-thru is more appealing than taking the time to have a sit-down meal at home with family. This means that families are consuming (in general) foods that are higher in fat and sodium, and lower in fiber and protein. Since children mimic their parents’ behavior, it only makes sense that they keep the same eating habits as their parents, and continue eating fast food as they grow, often becoming overweight as a result. Finally, there are global risk factors that have added to the prevalence of childhood obesity. In America, especially, there seems to be a large emphasis on high-demand careers and making money. As a consequence to this type of lifestyle, the thought and time people put into making healthy food choices has decreased and so has the importance of physical activity. Microwaveable meals have become very popular in the last decade, but one does not get all the nutrients they need from an “instant meal” diet, and obesity is one result of this. Media also plays a large role in the development of childhood obesity. There is much less advertisements of healthy foods as opposed to unhealthy, sugary, fatty, salty foods. Children would rather drink a sugary pop during lunch and cereal with a leprechaun on it rather than one with a heart and bland looking oats. Nutrition Therapy & Pathophisiology, pg. 249 health consequences associated with an overweight condition. Describe how these health consequences differ for an overweight versus an obese condition.There are many types of health consequences associated with an overweight condition. The emotional effects play a strong role, especially when the media portrays “perfection” as being extremely skinny for women, and perfectly toned and muscular for men. Due to this distortion, one is more likely to have adverse feelings about their body image, and overweight individuals may begin to feel depressed with low-self worth. The physiological conditions are severe as well. The prevalence of Type II diabetes, which is an insulin resistance often brought on by excessive body fat, is three times more likely to develop in someone who is overweight or obese. High blood pressure is another serious health consequence. It, too, is three times more likely to occur in someone who is overweight rather than normal weight, and if not treated, may lead to heart attack, heart disease, or even premature death. Lipid abnormalities are also experienced because excess fat often leads to high levels of LDL-cholesterol, total triglyceride levels, as well as high cholesterol. These are all extremely dangerous conditions that are associated with a high risk of Cardiovascular Disease and potentially even death. One is also more likely to develop gallstones, which cause severe pain and blockage of the bile duct. Being overweight is also associated with developing various cancers such as colon, gallbladder, kidney, etc. There are reproductive complications that arrive from being overweight in women as well. There are more menstrual abnormalities (ex: PCOS), higher likelihood of fetal and maternal death, gestational diabetes, and C-section deliveries. Finally, breathing problems, such as sleep apnea, are more likely to occur in overweight individuals.Although a lot of these consequences are common in overweight as well as obese people, the risk level one has for developing health consequences is higher in an obese individual versus overweight. If one is overweight, their BMI ranges from 25-29.9 kg/m^2, and one falls into the obese category if their BMI is greater than 30 kg/m^2. This value relates to the amount of body fat one holds, and the more body fat, the higher the risk of health consequences such as type II diabetes, hypertension, dyslipidemia, CHD, and metabolic syndrome. Another classification to look at among overweight and obese individuals waist circumference. A waist circumference that is > 40 in men and >34 in women also put them at a much higher risk for adverse health problems.Nutrition Therapy & Pathophisiology, pg. 248, 253-256Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea. Explain the relationship between sleep apnea and obesity.Sleep apnea is defined as having one or more pauses in breathing or shallow breaths while sleeping. Obstructive sleep apnea (OSA) is the most common type, where the airway becomes blocked or constricted while sleeping. The pauses in breathing may last for a couple seconds to even minutes and occur up to 30 times every hour, and are accompanied by choking, loud snorting, or gasps for breath before the next pause in breathing begins again. It is difficult to diagnose sleep apnea because people will not know they have this disorder unless a partner or roommate is able to notice the sleep disturbances. As a result of sleep apnea, individuals tend to sleep lightly and feel more tired and cranky throughout the day. OSA is linked to the development of diabetes, CVD, obesity, and depression. If gone untreated, the result may be as severe as heart failure. Obesity may be the cause of sleep apnea and as mentioned, is a side effect as well. Short sleep durations may result in metabolic changes linked to obesity. Sleep is especially critical to children and infants because their bodies are still growing and developing, and their hypothalamus may be compromised from lack of sleep as a result, which may alter appetite and energy expenditure. If one is already overweight or obese, the buildup of fat around the throat may narrow the airway during sleep enough to cause sleep apnea as well. are the goals for weight loss in the pediatric population? Under what circumstances might weight loss in overweight children not be appropriate?According for the U.S. Department of Health and Human Services, the Pediatric Weight Management (PWM) system, which assesses pediatric foods in overweight children, recommends short-term and long-term multicomponent goals. First, the PWN recommends decreasing the total amount of dietary fat intake and calorically sweetened beverages because they are positively associated with childhood weight gain. In addition, children should increase their intake of fruits and vegetables as well as dairy and calcium because all are directly associated with maintaining healthy weight. In terms of diet pattern behaviors at home, parents should restrict highly palatable foods, consumption of food majorly eaten outside the home, increased portion size of meals, snack frequency, and skipping breakfast. Regular physical activity and sports participation are also recommended to aid in healthy weight loss goals. Negative aspects of family functioning may have negative effects on childhood weight as well, such as lack of parental support or not encouraging them to eat healthy foods. Family support and cohesion as well as increased meals at home, on the other hand, have positive effects on weight loss for children. In terms of energy-restriction diets, if appropriate based on the registered dietitian's professional judgment, then a?balanced macronutrient diet?that contains no fewer than 900 kcals/day is recommended to improve weight status in?children ages 6 -12?who are medically monitored. Research indicates that balanced macronutrient diets at 900 to 1200 kcals/day are associated with both short-term and long-term weight status and body composition among 6 to 12-year-old children. For adolescents 13-18, the same procedure may be implemented if necessary except with an energy intake of 1,200 kcals/day.Weight loss in overweight children may not be appropriate under certain circumstances such as for young children who are still growing. They need to focus more on maintaining their current weight and reducing their rate of weight gain, allowing them to grow into their weight. Even if the child is extremely overweight, the weight loss should be general, ~1-2 lbs /day, and this should be supervised by a physician. would you recommend as the current focus for nutritional treatment of Missy’s obesity?For Missy’s nutritional treatment, the main nutrition focus should be to decrease the amount of fat in the diet and increase the amount of whole grains, fruits, and vegetables, as well as focus on portion control. According to the biochemical data, Missy’s cholesterol and LDL cholesterol levels are higher than the healthy ranges they should be in, and her decreased intake of fat in addition to regular physical activity should help to better maintain her lipid levels and improve Missy’s nutritional status.Overweight or obesity in adults is defined by BMI. Children and adolescents 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.According to the World Health Organization, the U.S. BMI 85th percentiles for international use to define 'at risk of overweight' for adolescents aged 10–19?years, and to define overweight, use both the BMI 85th percentiles and triceps skin fold thickness of 90th percentile. For children under 10?years of age, they recommended using weight-for-height?Z-score (WHZ>2) to classify 'overweight'. defines overweight in children according to the percentile where their BMI falls, and compare that value on a chart to other adolescents and teens of the same age and gender. Having a BMI less than the 5th percentile is considered underweight, 5th-85th percentile is normal weight, the 85th-95th is overweight, and greater than the 95th is considered obese.According to the CDC, “BMI is a measure used to determine childhood overweight and obesity. It is calculated using a child's weight and height. BMI does not measure body fat directly, but it is a reasonable indicator of body fatness for most children and teens. A child's weight status is determined using an age- and sex-specific percentile for BMI rather than the BMI categories used for adults because children's body composition varies as they age and varies between boys and girls.”According to these findings, and CDC’s definitions for overweight and obese in the pediatric population the same way. They differ from the WHO, which also takes skin fold thickness measurements into account. 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 indentified in question 6?According to the CDC growth charts, Missy’s BMI percentile falls slightly above the 97th percentile.According to each of the standards identified in the previous question, her weight status would be classified as obese because her BMI falls in the 97th percentile according to definitions provided by as well as the CDC and the World Heath OrganizationIf 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.One method that could be used to calculate Missy’s minimum energy requirements is through the Mifflin-St. Jeor formula for women:REE= 10 x weight [kg]) + 6.25 x height [cm]) – 5 x age -16110 x 52.3 + 6.25 x 144.8 – 5 x 10 -161= 1,217 kcals or ~1,200 kcalsAnother method for determining Missy’s energy requirements is through the Harris-Benedict formula, which takes into account sex, age, and weight:REE= 655 + (9.56 x weight (kg)) + (1.85 x height (cm)) – (4.68 x age)REE= 655 + (9.56 x 52.3) + (1.85 x 144.8) – (4.68 x 10)=1,376 kcals or ~1,400 kcalsAlthough these two formulas differed slightly, they both estimated the approximate the same amount of energy Therapy & Pathophysiology, pg. 241Dietary factors associated with increased risk of overweight are increased *dietary fat intake and increased ~kilocalorie-dense beverages. Identify foods from Missy’s diet re-call 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.Below is a chart of Missy’s 24-hr recall. From her intake, the foods rich in *dietary fat include whole milk, cream, bologna, Twinkies, Fritos chips, fried chicken, fried okra, and sweet popcorn. The kilocalorie dense ~beverage she consumed primarily is whole milk (28 oz.) as well as 12 oz. of coca-cola.Food Item% CHO% Fat% ProteinBfast burritos (2)19%21%38%*~ Whole milk (28 oz.)13%43%55%Apple juice (4 oz.)5%0%0%Coffee (6 oz)0%0%0%*Cream (1/4 c.)1%11%4%Sugar (2 t.)3%0%0%*Bologna (2 slices)1%21%17%American cheese (2 slices)1%21%20%White bread (4 slices)26%8%24%*Mayo (1 T.)0%17%0%*Frito corn chips (1 pkg)5%15%4%*Twinkies (2)18%14%8%Peanut Butter (2 T.)2%25%15%Grape Jelly (2 T.)6%0%0%*Fried chicken (2 legs, 1 thigh)0%27%107%Mashed potatoes (1 c.)12%2%8%*Fried okra (1 c.)4%20%5%Sweet tea (20 oz.)10%0%0%*Popcorn (3 c.)5%12%6%* Coca-cola (12 oz.)12%0%1%Approximate calories consumed: 4,000 kcalsIncreased fruit and vegetable intake is associated with decreased risk of overweight. Using Missy’s usual intake, is Missy’s fruit and vegetable intake adequate?According to the 24-hr recall, it seems as though Missy’s intake of fruits and vegetables is definitely not adequate. She did not consume any fresh fruit, except for a small amount of apple juice, which is a sugary beverage as well. The only vegetables she consumed was fried okra, which doesn’t contain the same nutrient amounts as fresh okra, and due to the fact that it’s fried, it adds 20% of total fat for that day, which shows that the negative outweigh the benefits of fried okra consumption in Missy’s diet.Use the MyPyramid Plan online tool to generate a personalized MyPyramid for Missy. Using this eating pattern, plan a 1-day menu for Missy.In 2011, the USDA implemented a new type of “MyPyramid”, known as “MyPlate” along with new food patterns for the 2010 Dietary Guidelines for Americans. Although the “My” part remains the same to convey the importance of a personalization approach, “MyPlate” is in the shape of a plate with easy to read visual foods, indicating where that food group should go on your “plate” and the servings as well. Thus, this is the method used to generate Missy’s personalized eating plan:In order to create a 1-day menu plan for Missy, MyPlate has set recommendations based on a 1,600 calorie diet, with 5 oz. of grains, 2 cups of vegetables, 1.5 cups of fruits, 3 cups of dairy, and 5 oz. of protein.BreakfastMorning SnackLunchAfternoon SnackDinnerEvening Snack-Whole wheat toast (1 slice)-1 T. reduced-sodium PB-1 egg-white scrambled egg topped on toast/PB-Med. red apple-8 oz. skim milk-1 c. honey-vanilla Greek yogurt-Med. banana-Sliced turkey sandwich on whole wheat bread (tomatoes, lettuce, 1 slice low-fat American cheese)-8 oz. skim milk-1 c. carrots-1/2 T. Fat free ranch dressing-8 oz. iced water-3 oz. lemon zest grilled chicken breast w/ cooked broccoli (no salt added)-1 whole wheat dinner roll with no added butter-8 oz. skim milk-1/2 c. Sliced strawberries-2 scoops chocolate sherbet -1 serving whole-grain popcorn with no added salt or butterNow enter and assess the 1-day menu you planned for Missy using the MyPyramid Tracker online tool. Does your menu meet the macro- and micronutrient recommendations for Missy?The MyPyramid Tracker has been changed to the “SuperTracker”After inputting Missy’s 1-day menu into SuperTracker, I came very close to meeting all the macronutrient recommendations. She surpassed or met her recommendations for whole grains, fruits, milk & yogurt, as well as protein. Her vegetable intake was almost met, but I should have added more during one of her meals. Lunchtime would have been a good time to add more vegetables. Between the calculations from question 8 about her energy needs and MyPlate, her average intake of calories should fall between 1,300-1,600 kcals, and according to this 1-day menu, her energy intake falls between this range. Why did Dr. Null order a lipid profile and a blood glucose test?By ordering a lipid profile test, Dr. Null can evaluate Missy’s risk of developing coronary heart disease. If one’s total cholesterol, LDL cholesterol, and triglyceride levels are above normal ranges, in increases the likelihood of heart attack or stroke. In addition to that are having HDL levels below the healthy range. Dr. Null ordered a blood glucose test because this will screen Missy for high or low blood sugar levels (hyper and hypoglycemia). From these findings, Dr. Null can determine if Missy has or is a risk for developing diabetes. In addition, due to her family history of diabetes, Missy is especially at a high risk. lipid and glucose levels are considered to be abnormal for the pediatric population?A normal blood glucose range would be 60-100 mg/dLA prediabetes, impaired fast glucose range would be 100-126 mg/dLA diabetes diagnosis would be 126+ mg/dLTotal cholesterol levels: 120-199 mg/dL= healthy range 200-239 mg/dL= borderline high 240+ mg/dL= high blood cholesterolHDL cholesterol levels: >60 mg/dL= best protection against heart disease 40-59 mg/dL= normal range <40 mg/dL= major risk factor for heart diseaseLDL cholesterol levels: <100 mg/dL= optimal 100-129 mg/dL= near optimal 130-159 mg/dL= borderline high 160-189 mg/dL= high 190+ mg/dL= very highTriglyceride levels: <150 mg/dL= normal 150-199 mg/dL= berderline high 200-499 mg/dL= high 500 mg/dL+ = very high Therapy & Physiology, pg. 301Evaluate Missy’s lab results.Missy’s lab results have some abnormally high values that are of concern regarding her risk for developing diabetes as well as reasons for her sleep apnea disorder. First, her glucose level was at 108 mg/dL, and this puts her within the prediabetes category, meaning her risk is high, especially paired with her family history. Her cholesterol levels fell within the healthy range, at 190 mg/dL, and her LDL level was near optimal. In addition, her triglyceride levels also appear normal, and her HDL cholesterol levels were also in a normal range. Overall, her lipid profile appears healthy and her risk for developing coronary heart disease is not high at the present time. There are two other lab readings, however, that do raise concern. Missy’s ammonia levels fell below the normal range of 0-33 umol/L. Ammonia is produced when proteins are digested in the intestines and then converted to urea in the liver, and low ammonia usually coexists with excessive sleepiness. Missy claims to be very tired and irritable during the day, and although that is likely due to her sleep apnea, low ammonia levels may be a contributing factor. Finally, her HbA1c level was .3% higher than the normal range. HbA1c are the red blood cells that are composed of hemoglobin that glucose sticks to in the blood. In a lab test, HbA1c levels shows how high one’s blood glucose has been on average over the past ~3 months. Checking for HbA1c is currently one of the best ways to test for diabetes and how well it has been controlled. Due to the fact that Missy’s HbA1c levels appeared higher than normal, it indicates that she is at high risk for developing diabetes. behaviors associated with increased risk of overweight would you look for when assessing Missy’s and her family’s diets?The first behavior I would look for that’s associated with risk of overweight is the frequency of Missy and her family’s meals. Next, I’d assess how often they eat at restaurants versus meals at home. If they eat out more often, then they’re more likely to consume high sodium and high fat foods. I’d also look at their physical activity patterns because if they tend to have a more active lifestyle, then their risk of being overweight decreases.What aspects of Missy’s lifestyle place her at increased risk for overweight?Missy lives a low-active lifestyle in combination with a high-energy intake, and when one takes in more energy than they expend, it causes one to gain weight, putting them at higher risk for being overweight. Not only does Missy consume a high calorie diet, but the type of foods she chooses to eat are generally high in fat (especially saturated), sugar, sodium, and low in whole grains, fiber, fruits, and vegetables, increasing her risk further. 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?I would let the family know that snacking is acceptable between meals, however I would recommend that she choose foods higher in protein and carbohydrates (whole grains, preferably) and lower in fat. It should also be a snack, meaning only about 100-150 calories; the snack size should not be comparable to a meal. I would also say that rewarding children with a dessert is okay to do as well, but these rewards should come sparingly, not all the time, and the type of dessert chosen not be a processed food item. Placing a small amount of sugar on strawberries is an example of a dessert that would be all right to give Missy.Identify one specific physical activity recommendation for Missy.Missy should work up to doing 30 minutes of physical activity a day, and because that may be difficult at first. Because she is a ten-year-old girl, her workouts should be fun and not seem taxing and boring. Doing increments of jumping rope and going through an obstacle course in the backyard would be a fun workout of Missy as well as a great way to spend time with her mother or father. If Missy prefers to be indoors, then I’d recommend playing Wii fit video games, which are very popular and fun to do with a group of friends as well. Select two high-priority nutrition problems and complete PES statements for each.Excessive energy intake related to consumption of large portions of high-fat meals as evidenced by 24-hr recall analysis, weight status, and BMI in the 95th percentile.Sleeping difficulty related to consumption of energy-dense, empty caloric foods as evidenced by diagnosis of Obstructive Sleep Apnea, BMI of ~26 kg/m^2, irritability during the day, and low activity level.For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on etiology).PES 1: Excessive energy intake related to consumption of large portions of high-fat meals as evidenced by 24-hr recall analysis, weight status, and BMI in the 95th percentile.Ideal goal: Reduce energy intake to 1,200-1,300 calories/dayAppropriate intervention: Modification of eating habits: instruct Missy on choosing nutrient-dense foods and increasing her consumption of whole grains, dietary fiber, fruits, vegetables, and protein.PES 2: Sleeping difficulty related to energy-dense, empty caloric foods as evidenced by diagnosis of Obstructive Sleep Apnea, BMI of 26 kg/m^2, irritability during the day, and low activity level.Ideal goal: Increase physical activity level to 30 minutes/dayAppropriate intervention: Create an exercise plan that incorporates various types of workouts that are child-friendly.Mr. and Mrs. Bloyd ask about using over-the-counter diet aids, specifically Alli (orlistat). What would you tell them?I would not recommend Mr. and Mrs. Bloyd giving Missy an OTC, such as an orlistat, for several reasons. First of all, orlistat works by blocking some of fat that is consumed, preventing it from being absorbed by the body. Missy is still growing and needs fat as a part of a healthy diet, and orlistat would prevent this fat from helping Missy grow. These types of drugs are only for individuals 18 and over, and prescription orlistat could be prescribed to individuals 12-18 if advised by a doctor, yet this is still not safe for a ten-year-old. Missy needs to focus more on limiting her overall energy intake, not just fat.. and Mrs. Bloyd ask about gastric bypass surgery for Missy. What are the recommendations regarding gastric surgery for the pediatric population?Gastric bypass surgery is a very extreme solution to weight loss, and there are many risks involved. It should be a last result, after diet and exercise have failed. Thus I would not recommend this for Missy, because she still has a chance to improve her dietary and physical activity habits, and her BMI level has not yet reached the “Obese” classification. However, the prevalence of childhood and teenage obesity are on the rise, and the likelihood for these populations to continue their dietary behaviors and remain obese through adulthood is very high. Therefore, this might be an acceptable solution for certain pediatric candidates, specifically those with a BMI >40 kg/m^2, but again, this is an extreme and last resort. should the next counseling session with Missy be scheduled?Missy’s next counseling session should be scheduled as soon as possible. She needs to get the appropriate treatment for her sleep apnea and then start Nutrition counseling immediately. Should her parents be included? Why or why not?I would recommend that her parents be included in Missy’s follow-up appointments. She is only ten-years-old and her parents play a huge influence in her dietary decisions at this age, thus in order to keep Missy on tract with her dietary and physical activity recommendations made by the physician and/or R.D., they should attend the counseling sessions.What would you assess during this follow-up counseling session.At Missy’s next follow-up appointment, her current diet history and dietary behaviors should be assessed to know if Missy has been following her recommended plan. BMI and skin fold measurements should be taken as well to see if Missy has fallen into a healthy category for weight and thus decrease her risk for developing T.2 diabetes. In terms of blood tests, since her ammonia levels her low and her HbA1c levels were high initially, these values should be reviewed for assessment on improvement. These are the first steps to meeting Missy’s long-term goals for a lifelong wellbeing. ................
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