Childhood OverweightChildhood OverweightKayla KmetKayla Kmet

Lora Lee AaronLora Lee AaronRebecca WillisRebecca Willis

Stephanie HunleyStephanie Hunley

Case Study 1Case Study 1Missy Bloyd’s StoryMissy Bloyd’s Story

10/28/0910/28/09

• Client Name:Client Name: Missy Bloyd Missy Bloyd• Date of Birth:Date of Birth: 10/9 10/9• Age:Age: 10 10• Sex:Sex: Female Female• Education:Education: (5th grade) Less than (5th grade) Less than

high schoolhigh school• Occupation:Occupation: Student Student

MissyMissy

• Hours of Work:Hours of Work: Regular school Regular school hourshours

• Household members:Household members: Father (36), Father (36), mother (35), sister (5)mother (35), sister (5)

• Ethnic Background:Ethnic Background: Biracial Biracial (African American and Caucasian)(African American and Caucasian)

• Religious Affiliation:Religious Affiliation: Catholic Catholic• Referring Physician:Referring Physician: D. Null, MD D. Null, MD

MissyMissy

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• Sleep disturbance in last several years- Sleep disturbance in last several years- sleeping with mouth open, cessation of sleeping with mouth open, cessation of breathing for 10 sec, snoring, restlessness, breathing for 10 sec, snoring, restlessness, enuresis, morning headachesenuresis, morning headaches

• Changes in school grades/successChanges in school grades/success• Change in attention spanChange in attention span• Onset: unspecific, about a year agoOnset: unspecific, about a year ago• Tx: noneTx: none• Meds: noneMeds: none• Smoker: noSmoker: no• Family Hx:gestational diabetes, type 2 DM, in Family Hx:gestational diabetes, type 2 DM, in

mother and grandmothermother and grandmother

Missy’s HxMissy’s Hx

Height: 57 inHeight: 57 in

Weight: 115 lbsWeight: 115 lbs

Percentile: 98thPercentile: 98th

BMI: 24.95BMI: 24.95• According to the CDC, overweight in children 2-19 yo. is classified as According to the CDC, overweight in children 2-19 yo. is classified as

being at or above a BMI in the 85being at or above a BMI in the 85thth percentile. Obesity in 2-19 yo. is percentile. Obesity in 2-19 yo. is defined as being at or above a BMI in the 95defined as being at or above a BMI in the 95thth percentile. percentile.

• For every five point increase in BMI a person enters a higher bracket of For every five point increase in BMI a person enters a higher bracket of disease risk. The diseases and conditions do not necessarily increase in disease risk. The diseases and conditions do not necessarily increase in number, but in likelihood number, but in likelihood

• Overweight and obesity can come with several co morbidities and Overweight and obesity can come with several co morbidities and complications including: diabetes, gall bladder disease, hypertension, complications including: diabetes, gall bladder disease, hypertension, dyslipidaemia (too much fat in the blood), sleep apnea, coronary heart dyslipidaemia (too much fat in the blood), sleep apnea, coronary heart disease, osteoarthritis (deterioration of cartilage in knees), disease, osteoarthritis (deterioration of cartilage in knees), hyperuricaemia (too much uric acid in the blood) which may result in hyperuricaemia (too much uric acid in the blood) which may result in gout (swelling in feet from deposited uric acid), cancer, reproductive, gout (swelling in feet from deposited uric acid), cancer, reproductive, hormone abnormalities, polycystic ovarian syndrome, impaired hormone abnormalities, polycystic ovarian syndrome, impaired fertility, low back pain, increased anaesthetic risk (loss of sensation or fertility, low back pain, increased anaesthetic risk (loss of sensation or consciousness), and fetal defects from maternal obesity.consciousness), and fetal defects from maternal obesity.

AnthropometricsAnthropometrics

Text

• ““We’ve noticed that Missy appears We’ve noticed that Missy appears to stop breathing for several to stop breathing for several seconds several times a night. She seconds several times a night. She is really cranky when she gets up is really cranky when she gets up for school. Her teacher says Missy for school. Her teacher says Missy gets very sleepy during gets very sleepy during school...She fell asleep in class school...She fell asleep in class yesterday.”yesterday.”

Missy’s ComplaintMissy’s Complaint

• General: very good appetite, wide General: very good appetite, wide vatiety of foodvatiety of food

• Food allergies/intolerances: NKAFood allergies/intolerances: NKA• Previous Nutrition Therapy? NoPrevious Nutrition Therapy? No• Food Purchase/Preparation: Food Purchase/Preparation:

Parent(s)Parent(s)• Vit/Min Intake: Flintstones vitamin Vit/Min Intake: Flintstones vitamin

dailydaily

Missy’s Nutritional HxMissy’s Nutritional Hx

• AM: 2 breakfast burritos, 8oz whole milk, AM: 2 breakfast burritos, 8oz whole milk, 4oz apple juice, 6oz coffee with 1/4 c 4oz apple juice, 6oz coffee with 1/4 c cream and tsp sugarcream and tsp sugar

• LUNCH: 2 bologna and cheese LUNCH: 2 bologna and cheese sandwiches with 1tbsp of mayo, 1 oz sandwiches with 1tbsp of mayo, 1 oz package Frito corn chips, 2 twinkies, 8 oz package Frito corn chips, 2 twinkies, 8 oz whole milkwhole milk

24 Hour Recall24 Hour Recall

• AFTER SCHOOL SNACK: Peanut butter and jelly AFTER SCHOOL SNACK: Peanut butter and jelly sandwich (2 slices enriched bread with 2 tbsp sandwich (2 slices enriched bread with 2 tbsp crunch peanut butter and 2 tbsp grape jelly), 12 oz crunch peanut butter and 2 tbsp grape jelly), 12 oz whole milkwhole milk

• DINNER: Fried chicken (2 legs and 1 thigh), 1 c DINNER: Fried chicken (2 legs and 1 thigh), 1 c mashed potatoes (whole milk/butter), 1 c fried mashed potatoes (whole milk/butter), 1 c fried okra, 20 oz sweet teaokra, 20 oz sweet tea

• SNACK: 3 c microwave popcorn, 12 oz Coca-ColaSNACK: 3 c microwave popcorn, 12 oz Coca-Cola

24 Hour Recall24 Hour Recall

• R/O Obstructive Sleep Apnea (OSA) secondary R/O Obstructive Sleep Apnea (OSA) secondary to obesity and physical activityto obesity and physical activity

• OSA: OSA: Sleep apnea is a breathing disorder apnea is a breathing disorder characterized by brief interruptions of characterized by brief interruptions of breathing during breathing during sleep. .

• There are two types of There are two types of sleep apnea: central : central and obstructive.and obstructive.

• Central sleep apnea occurs when the brain Central sleep apnea occurs when the brain fails to send the appropriate signals to the fails to send the appropriate signals to the breathing muscles to initiate respirations.breathing muscles to initiate respirations.

• Obstructive sleep apnea occurs when air Obstructive sleep apnea occurs when air cannot flow into or out of the person's nose or cannot flow into or out of the person's nose or mouth although efforts to breathe continue.mouth although efforts to breathe continue.

DxDx

• PolysomnographyPolysomnography• FBGFBG• HbA1CHbA1C• Lipid PanelLipid Panel• Psychological EvaluationPsychological Evaluation• Nutrition AssesmentNutrition Assesment

Tx PlanTx Plan

• Two Part AnalysisTwo Part Analysis

Missy’s AssesmentMissy’s Assesment

•Testing

•Lab Results

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•Blood Glucose Test-Helps to determine whether individuals are hyperglycemic, hypoglycemic, or if individuals have diabetes

•Lipid Profile-Helps to determine whether there is a risk for heart disease by measuring cholesterol, triglycerides, HDL, and LDL levels.

TestingTesting

•Missy’s Blood Glucose Level- 108 mg/dL

•Normal Levels- 70-110 mg/dL Prediabetes- 100 mg/dL Diagnosis of Diabetes- 100-126 mg/dL

Blood Glucose LevelsBlood Glucose Levels

• Missy’s Blood Glucose Level- 108 mg/dLMissy’s Blood Glucose Level- 108 mg/dL• -Her current level places her in the higher end of the -Her current level places her in the higher end of the

normal range and in the prediabetes area.normal range and in the prediabetes area.

• Contributing FactorsContributing Factors• -weight, poor insulin circulation, over consumption of -weight, poor insulin circulation, over consumption of

carbohydrates carbohydrates

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Evaluation of Missy’s Evaluation of Missy’s Blood Glucose LevelBlood Glucose Level

1919

Missy’s Lipid Profile Missy’s Lipid Profile ResultsResults

CholesterolCholesterol 190190

LDLLDL 110110

HDLHDL 5050

TGTG 114114

• Normal LevelsNormal Levels vs.vs. Missy’s Missy’s LevelsLevels

• Cholesterol-120-199mg/dL 190mg/dLCholesterol-120-199mg/dL 190mg/dL

• LDL- <130mg/dL 110mg/dLLDL- <130mg/dL 110mg/dL

• HDL- >55mg/dL 50mg/dLHDL- >55mg/dL 50mg/dL

• TG- 35-135mg/dL 114mg/dLTG- 35-135mg/dL 114mg/dL

Evaluation of Missy’s Evaluation of Missy’s Lipid ProfileLipid Profile

• Physical Activity Level- sedentaryPhysical Activity Level- sedentary

• --Includes reading and playing video Includes reading and playing video gamesgames

Activity LevelActivity Level

• EER for Girls 9 Through 18 YearsEER for Girls 9 Through 18 Years• EER = TEE + energy depositionEER = TEE + energy deposition• EER = 135.3 − (30.8EER = 135.3 − (30.8 × × age [y]) + PAage [y]) + PA × × (10.0(10.0 × × weight weight

[kg] + 934[kg] + 934 × × height [m]) + 25 kcalheight [m]) + 25 kcal• Where PA is the physical activity coefficient:Where PA is the physical activity coefficient:• PA = 1.00 if PAL is estimated to be ≥ 1.0 < 1.4 (sedentary)PA = 1.00 if PAL is estimated to be ≥ 1.0 < 1.4 (sedentary)• PA = 1.16 if PAL is estimated to be ≥ 1.4 < 1.6 (low active)PA = 1.16 if PAL is estimated to be ≥ 1.4 < 1.6 (low active)• PA = 1.31 if PAL is estimated to be ≥ 1.6 < 1.9 (active)PA = 1.31 if PAL is estimated to be ≥ 1.6 < 1.9 (active)• PA = 1.56 if PAL is estimated to be ≥ 1.9 < 2.5 (very active)PA = 1.56 if PAL is estimated to be ≥ 1.9 < 2.5 (very active)

• Missy: Age 10 yrs PA 1.0 Weight kg=52.3 Height m= Missy: Age 10 yrs PA 1.0 Weight kg=52.3 Height m= 1.45 1.45

• EER= 135.3- (30.8 x10) + 1.0 x (10.0 x 52.3kg + 934x EER= 135.3- (30.8 x10) + 1.0 x (10.0 x 52.3kg + 934x 1.45m) + 25 kcal1.45m) + 25 kcal

• EER= 135.3- 308 + 1.0 x 1877.3 + 25kcalEER= 135.3- 308 + 1.0 x 1877.3 + 25kcal• EER= 1729.6 kcalEER= 1729.6 kcal

Missy’s EnergyMissy’s Energy

• Energy RequirementsEnergy Requirements• 1729.6 kcal1729.6 kcal

• Energy IntakeEnergy Intake• -includes high fat and high starch foods with -includes high fat and high starch foods with

inadequate fruit and vegetable intakeinadequate fruit and vegetable intake

• Energy Breakdown:Energy Breakdown:• Total calories= 4435 kcals Total calories= 4435 kcals • Energy dense beverages= 402 kcalsEnergy dense beverages= 402 kcals

• 9.06% of total calories9.06% of total calories• High fat foods= 2697 kcalsHigh fat foods= 2697 kcals

• 60.81 % of total calories60.81 % of total calories

Missy’s EnergyMissy’s Energy

• Energy Intake- Energy Intake- High fat and high carbohydrate High fat and high carbohydrate content of food with a low energy output.content of food with a low energy output.

• Blood Glucose Test- Blood Glucose Test- Due to her weight and Due to her weight and high carbohydrate consumption her insulin levels are high carbohydrate consumption her insulin levels are not keeping up with her blood glucose levels, which not keeping up with her blood glucose levels, which places her at risk for type II diabetes. places her at risk for type II diabetes.

• Lipid Profile- Lipid Profile- Elevated levels indicate she is at Elevated levels indicate she is at risk for developing cardiovascular disease as well. risk for developing cardiovascular disease as well.

Missy’s AssessmentMissy’s Assessment

• Missy’s Nutrition Diagnosis ~ PESMissy’s Nutrition Diagnosis ~ PES

• Excessive energy intake related to energy-dense Excessive energy intake related to energy-dense food choices as evidenced by estimated energy food choices as evidenced by estimated energy intake of 4,435 kcals based on 24 hour recall.intake of 4,435 kcals based on 24 hour recall.

• Physical inactivity related to preference for Physical inactivity related to preference for sedentary activities as evidenced by report of sedentary activities as evidenced by report of enjoying video games and reading.enjoying video games and reading.

Missy’s Diagnosis and Missy’s Diagnosis and Treatment PlanTreatment Plan

• Missy’s Nutrition Intervention-Based on PES Missy’s Nutrition Intervention-Based on PES statementsstatements

• 1) Excessive energy intake.1) Excessive energy intake.• Goal: for Missy to achieve appropriate energy Goal: for Missy to achieve appropriate energy

intake levels.  intake levels.  • Intervention: nutrition education for Missy and Intervention: nutrition education for Missy and

her parents covering:her parents covering:• Portion ControlPortion Control• Balancing intake based on physical activity levelBalancing intake based on physical activity level• Healthy cooking techniques/ meal and snack ideasHealthy cooking techniques/ meal and snack ideas• Health risks of chronic overweightHealth risks of chronic overweight

Missy’s TreatmentMissy’s Treatment

• Missy’s Nutrition Intervention-Based on Missy’s Nutrition Intervention-Based on PES statementsPES statements

• 2) Physical Inactivity.2) Physical Inactivity.• Goal: to increase Missy’s physical activity.Goal: to increase Missy’s physical activity.• Intervention: encourage her to play more Intervention: encourage her to play more

outside the house, in addition, we outside the house, in addition, we recommend that she enroll in an after school recommend that she enroll in an after school sports program of her choice (soccer, sports program of her choice (soccer, basketball, volleyball, swimming, etc) so that basketball, volleyball, swimming, etc) so that she can be more active and enjoy it.  she can be more active and enjoy it. 

• Also, we recommend Missy get a Wii system Also, we recommend Missy get a Wii system so she can be more active during her screen so she can be more active during her screen time.time.

Missy’s TreatmentMissy’s Treatment

Missy’s MyPyramidMissy’s MyPyramid

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• Day 1Day 1• BreakfastBreakfast• 1% milk (low fat) 1% milk (low fat) • Oatmeal (plain) Oatmeal (plain)

• 1% milk (low fat) 1% milk (low fat) • Blueberries (raw) Blueberries (raw)

• LunchLunch• Fat free milk (skim) Fat free milk (skim) • Wrap sandwich (meat, vegetables, rice)Wrap sandwich (meat, vegetables, rice)

Missy’s MenuMissy’s Menu

• DinnerDinner• Fat free milk (skim) Fat free milk (skim) • Chicken, veggies & noodles (cream sauce) Chicken, veggies & noodles (cream sauce) • Raw carrots Raw carrots

• Creamy dressing (ranch) Creamy dressing (ranch) • Wheat roll (part whole wheat)   Wheat roll (part whole wheat)  

• SnackSnack• Banana Banana • Lowfat cottage cheese Lowfat cottage cheese • Cucumber Cucumber

• Italian dressing (oil and vinegar) Italian dressing (oil and vinegar)

• Canned tuna (in oil)Canned tuna (in oil)

Missy’s MenuMissy’s Menu

Missy’s Menu Missy’s Menu AssessmentAssessment

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Monitoring and Monitoring and EvaluationEvaluation

• Next counseling session for Missy should be Next counseling session for Missy should be scheduled as soon as possible, needs to get scheduled as soon as possible, needs to get appropriate treatment for sleep apnea and appropriate treatment for sleep apnea and then start Nutrition counseling immediately.then start Nutrition counseling immediately.

• Her parents should definitely be included in Her parents should definitely be included in her counseling sessions, they are preparing her counseling sessions, they are preparing her meals.her meals.

• In follow up visit, assess short term goals that In follow up visit, assess short term goals that were originally set, these are first steps to her were originally set, these are first steps to her long term goals.  We would assess any long term goals.  We would assess any changes in physical activity and dietary changes in physical activity and dietary behavior.behavior.

• What put Missy at risk for What put Missy at risk for becoming overweight?becoming overweight?

• Childhood Obesity~ CausesChildhood Obesity~ Causes• GeneticsGenetics• Behavioral/environmentalBehavioral/environmental• Global trends/ Personal HabitsGlobal trends/ Personal Habits

Missy’s Lifestyle Missy’s Lifestyle and Our Cultureand Our Culture

• Alli/OrlistatAlli/Orlistat• Not For ChildrenNot For Children

• Gastric Bypass SurgeryGastric Bypass Surgery• Not For ChildrenNot For Children

• Healthy Diet and Physical ActivityHealthy Diet and Physical Activity• Appropriate for AnyoneAppropriate for Anyone

Missy’s Weight Loss Missy’s Weight Loss OptionsOptions

• Goals for pediatric weight lossGoals for pediatric weight loss• Who is involved?Who is involved?

• FamilyFamily

• What are they eating?What are they eating?• Food DiaryFood Diary• Portion ControlPortion Control

• Weight managementWeight management• Healthier eating choicesHealthier eating choices• More physical activity/less sedentary More physical activity/less sedentary

activityactivity

Missy and Her PeersMissy and Her Peers