Jessica Pitzer

KNH 411

Case Study Childhood Overweight

10/13/14

Case Questions

Childhood Overweight

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 on 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).

Childhood obesity is proven to be linked to many different factors such as

genetics, environment, and global factors. Genetics affects body weight and body

composition by influencing such factors as appetite, taste preferences, energy intake,

resting energy expenditure, the thermic affect of food, non-exercise activity

thermogenesis, and the body’s efficiency in storing energy. Each person’s body has a

genetically determined metabolic “set-point” that maintains a preferred body weight.

Obesity is not inherited in families in a predictable manner. This lack of predictability

indicates that multiple genes are involved, with each making a small contribution to body

weight and how a person responds to environmental factors like diet, physical activity,

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and culture. The weight of scientific evidence indicates that some people are more prone

to obesity than other due to genetic factors, and that 40%-50% of the variation in BMI is

explained by genetic factors. However, environment factors probably play a greater

etiologic role for most people, particularly in light of the fact that famine prevents obesity

even in the most obesity prone individuals. As important as genetic influences are,

persons born with a genetic predisposition to obesity are not necessarily destined to a life

of obesity. An individual’s environment plays the biggest role obesity. The term “toxic

food environment” aptly describes the convenient availability of low-cost, tasty, energy-

dense foods, in large portion sizes, in North America and the developed world. The toxic

food environment encourages a high-energy intake and has been a major contributing

factor in the epidemic of overweight and obesity. Over the past several decades,

important changes in the eating habits of North Americans have contributed to the

increased prevalence of overweight and obesity. Socioeconomic status can also follow

under this problem. The low cost foods such as fast foods, tend to be high in saturated

and trans fats, sodium, and energy. This all contributes to the obesity epidemic. (Nelms

253-258)

2. Describe health consequences associated with an overweight

condition. Describe how these health consequences differ for

overweight versus an obese condition.

Being overweight and obese has horrible affect on the body. It not only affects the body

physically, it causes a lot of psychosocial and emotional consequences. In North

America, the combination of a think standard of beauty with fat ways of living has

resulted in the current era being referred to by some as “the age of caloric anxiety”.

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Because of the strong pressures form society to be thin, overweight and obese people

often suffer feeling of guilt, depression, anxiety, and low self-worth. Some of the

physiological consequences include type 2 diabetes, high blood pressure, lipid

abnormalities, hepatobiliary disorders, cancers, reproductive disorders, and premature

death. Type 2 diabetes is three times as prevalent among the obese as compared with

normal-weight persons. Similarly high blood pressure is three times more common in

obese than in normal-weight persons. Hyperglycemia and hyperinsulinemia are also

associated with obesity increasing blood pressure through several mechanisms that are

not well understood. Obese adults are more likely than normal-weight adults to have

elevated serum levels of total and low-density lipoprotein (LDL) cholesterol and

triglycerides, as well as lower serum levels of high-density lipoprotein (HDL)

cholesterol. Elevated serum LDL-cholesterol and low serum HDL-cholesterol are major

risk factors for coronary heart disease. There is a six fold increased risk of symptomatic

gallstones in persons whose body weight is 50% more than recommended. Cancer has

been on the rise and a number of studies have confirmed that obesity is a significant risk

factor for death from cancer. Obesity can also lead to reproductive disorders in both

males and females. In males it’s associated with gynescomasita and in females menstrual

abnormalities. (Nelms 252-255)

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 a common disorder in which you have one or more pauses in

breathing or shallow breaths while you sleep. Breathing pauses can last from a few

seconds to minutes. They may occur 30 times or more an hour. When you sleep, all of

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the muscles in your body become more relaxed. This includes the muscles that help keep

your throat open so air can flow into your lungs. When they are obstructed this can lead

to waking up unrefreshed, feeling sleepy, acting grumpy, and forgetful due to lack of

sound sleep. This is expressed in her chief complaint that she stops breathing several

times a night, is cranky when she wakes up, is very sleepy during school, and falls asleep

in class. Typically, normal breathing then starts again, sometimes with a loud snort or

choking sound. Sleep apnea is largely associated with being overweight. The problem of

obesity in children is a major concern for many reasons including the increased incidence

of sleep apnea. A 20-year review of obesity-associated disease among children aged 6 to

17 conducted by the CDC found a significant increase in hospital discharges for a number

of obesity-related medical conditions. Sleep apnea leads to daytime sleepiness, and this

can be hard to maintain an active life style. (National Heart, Lung, and Blood Institute,

National Sleep Foundation, MedlinePlus)

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?

Weight loss in the pediatric population can be a complicated subject. Children are still in

the growing process, so an adequate diet with the sufficient vitamins and minerals is very

important. The goal is to maintain baseline weight initially, and then add slow changes in

eating and exercise to achieve slow weight loss as recommended. The child should be

eating a variety of foods that are low in calories. There should be a focus to decrease

consumption of high-fat foods, eating more vegetables and fruit, eating fewer sweets,

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candy, cookies, chips, and sodas, changing to skim milk, and referring to support groups.

The energy needs of the child should not fall under the amount to stop growth. The

adolescent’s energy needs should always be met, just not in access. Weight loss in

children may not be appropriate in very young children and babies. A better option

would be to lower high-energy foods consumed and switch to better options like fruit and

vegetables. It may also be dangerous for children who are sick or have a chronic illness

to diet.

5. What would you recommend as the current focus for nutritional

treatment of missy’s obesity?

For treatment of Missy’s obesity I would focus on the energy balance in Missy’s diet. At

her age, she is in the range for the program to maintain her current weight and grow into

her body. By making healthier food choices Missy can maintain energy expenditure with

consume an adequate amount of the macro and micronutrients. Some of these choices

include an increase in fruits, vegetables, whole grains, low fat dairy products, and low fat

meat products. Decreasing sodium and saturated fat would also help to improve Missy’s

health. I would also increase her physical activity to help maintain that balance of energy

and make sure that Missy is not consuming access energy which would make her gain

more weight.

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 as “overweight” or “at risk for

overweight” based on their BMI percentiles, but this classification

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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 Nelms classification of pediatric BMI there are different percentiles that

a child can classify their health. A percentile of less and 5th percentile is classified as

underweight. A percentile of greater than or equal to the 5th percentile and less than the

85th percentile is considered to be health weight. A percentile of greater than or equal to

85th percentile and less than the 95th percentile is considered to be overweight. Anything

at or above the 95th percentile is considered to be obese. According to the centers for

disease control and prevention overweight is considered to be anything above the 85th

percentile but lower than 95th percentile. Obesity is considered to be at or above the 95th

percentile. This information is based from the ages 2-19 years of age. Kids Health agrees

with a lot of the ideas that Nelms and Centers for Disease Control and Prevention agree

with. Underweight is recognized as BMI below the 5th percentile. A BMI at the 5th and

less than the 85th percentile is normal weight. Overweight is considered to be a BMI at

the 85th and below 95th percentiles. Obese is a BMI at or above the 95th percentile.

(Nelms 247, Centers for Disease Control and Prevention, KidsHealth)

7. Evaluate 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 identified in question 6?

According to the CDC growth chart Missy’s BMI percentile for 115lb and 10 years old

she falls in the 95th percentile. A percentile of 95 or greater is considered to be obese

under the BMI classification scale. When comparing her height of 57 inches or 145

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centimeters she falls in the 85th percentile. The percentile 5-85 is considered to be a

healthy weight. Missy is on the far end of the spectrum. All of the following

classifications follow the sources in question number six. (Nelms Case Study Approach

5, Nelms 247)

B. Calculation of Nutrients Requirements

8. If possible, RMR should be measured by indirect calorimetry.

Identify two methods for determining Missy’s energy requirements.

The most commonly used approach for measuring energy requirements in critically ill

patients and in human metabolic research is indirect calorimetry. It is based on the fact

that energy expenditure is proportional to the body’s oxygen consumption and carbon

dioxide production. Missy’s energy requirement can be determined by two different

equations. The first one is estimated energy requirement or EER. This equation is the

average dietary energy intake that is predicted to maintain energy balance in a healthy

person of a defined age, gender, weight, height, and level of physical activity. Missy may

need to lose weight before she can get the full use of this equation because she is

considered an unhealthy weight. Missy’s EER was calculated at 2,025 kcals. Another

equation that can be used is total energy expenditure. This equation can be used for

overweight children. Missy’s TEE was calculated at 1,920kcals. (Nelms 245-247)

EER= 135.3−30.8× age+PA (10.0 × weight+934 ×height )+20

EER= 135.3−30.8× 10+1.16 (10.0× 52.3 kg+934 ×1.45 meters )+20

EER= 2025

TEE= 389−41.2 ×age+PA× 15.0 ×weight+701.6 ×height

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TEE= 389−41.2 ×10+1.18 ×15.0 ×52.3 kg+701.6 ×1.45 meters

TEE= 1920

BMI= Weight∈kg

height∈meters2

BMI= 52.3 kg

1.45 meters2

BMI= 18.0 kg/m2

9. Dietary fiber associated with increased risk of overweight is increased

dietary fat intake and increased kilocalorie-dense beverages. Identify

foods from Missy’s diet recall 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.

Missy’s diet consists of a lot of high fat foods and high kilocalorie-dense beverages.

Some of these items include breakfast burritos, whole milk, cream, apple juice, bologna,

peanut butter, fried chicken, fried okra, corn chips, Twinkies, sweet tea, and Coca-Cola.

Pretty much every single thing that Missy consumed was high in fat or empty calories.

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Missy consumed 4,746kcals, 204g of protein, 459g of carbohydrates, 21g of fiber, and

she consumed 45% of calories from fat. This means she consumed 816kcals of protein,

1,836kcals of carbohydrates, and 2,136kcals of fat.

204g x 4g/kcal= 816kcals

459g x 4g/kcal= 1,836kcals

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4,746kcals x 0.45= 2,136kcals

Missy consumed a lot of empty kilocalories from the fluids she consumed. From her 24-

hour recall, I calculated that she consumed 858 kcals from fluids. This means that she

consumed 18% of her calories from fluids.

858kcals/ 4,746kcals= 0.18= 18%

10. Increased fruit and vegetable intake is associated with decreased risk

of overweight. Using Missy’s usual intake, is Missy’s fruit and

vegetable intake adequate?

Missy’s intake of fruit and vegetables is far under adequate. The only fruits and

vegetables that Missy’s consumed in her 24 hour recall are mashed potatoes, okra, and

corn chips. None of these items were prepared in healthy ways. She consumed apple

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juice but this does not suffice as a good way to consume fruit. She did not reach the

recommended value of 1-½ cups of fruit and 2 cups of vegetables. (Super Tracker)

11. Use the MyPlate Plan online to generate a personalized MyPlate for

Missy. Using this eating pattern, plan a 1-day menu for Missy. (Super

Tracker)

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12. Now enter and assess the 1-day menu you planned for Missy using the

MyPlate tracker online tool. Does your menu meet macro-and

micronutrient recommendations for Missy?

After creating a new menu for Missy, her needs are more adequately met. I tried to keep

the menu as similar as possible with small healthy changes, so that Missy would comply

with the new diet. The new values were calculated at 1,977kcals, which is in the middle

of both the EER and TEE calculated at 1,920 and 2,025. With the new menu she will

consume 122g of protein, which is 25% from calories. This is a higher than the normal

range of 15%, but this is a lot lower than her 24-hour protein calculation. A little extra

protein may be a good thing for a growing child, especially if she increases her physical

activity as recommended. If this range becomes a problem then milk can be substituted

for water and we can use one piece of turkey instead of two. Her carbohydrate intake is

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recommended intake of 50-60% and this was adequately met at 56% of calories from

carbohydrates. Fat intake is recommended at a range of 25-35% from calories. Her new

menu contains 21% fat from calories. This is slightly under the range, but I believe that

this is okay for this value to be slightly lower than the recommended value because she is

taking in the minimum amount for daily function and she is overweight. Her sodium was

slightly over at 2,776 mg. It was recommended to be at or below 2,400mg. Lastly, her

dietary fiber has a target range of 26g but her new diet contains 32g of fiber. This is a

little above the recommendation, but still considered to be okay because its not far from

the recommendation. When comparing Missy’s 24-hour recall and her new one day diet,

her macronutrient amounts decreased significantly.

C. Clinical Domain

13. Why did Mr. Null order a lipid profile and a blood glucose test?

Mr. Null ordered a lipid profile and a blood glucose test because overweight and obese

children are more likely to have lipid and blood glucose health problems that can cause

heart problems later in life. He ordered a lipid panel to monitor Missy’s total cholesterol,

HDL, LDL, and triglyceride levels. The blood glucose tests the amount of glucose in

Missy’s blood, which can lead to diabetes. These test are important not only because

Missy has an inadequate diet, but also because she has a family history of heart problems,

high blood pressure, and diabetes. Missy is also at risk for metabolic syndrome because

she is overweight. Risk factors for heart disease, such as hyperlipidemia and

hypertension, occur more frequently in overweight and obese individuals than those in

the healthy weight range. (Nelms 256, Nelms Case Study Approach 4)

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14. What lipid and glucose levels are considered to be abnormal for the

pediatric population?

When researching abnormal levels of lipid ranges for the pediatric population the

following chart was discovered. (Healthy Children)

The following chart was found to illustrate the normal ranges of blood glucose levels.

Anything above or below these ranges is considered to be abnormal. (About Kids Health)

When looking at table 13.8 in Nelms, a table of the values of total cholesterol levels can

be found. Less than 200mg/dL is a desirable level that puts you at lower risk for heart

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disease; a cholesterol level of 200mg/dL or greater increases your risk. 200 to 239 mg/dL

is borderline high and 240mg/d and above is considered high blood cholesterol. HDL

cholesterol levels: less than 40mg/dL is a major risk for heart disease, 40-59mg/dL is

normal, 60mg/dL and above is considered protective against heart disease. LDL

cholesterol levels: less than 100mg/dL is optimal, 100-129mg/dL is near optimal, 130-

159mg/dL is borderline high, 160mg/dL and above is high. Triglyceride levels: less than

150mg/dL is normal, 150- 199 mg/dL is borderline high, and 200mg/dL and above is

considered high. (Nelms 301)

15. Evaluate Missy’s lab results.

The normal range for lipid and glucose levels are as follows: LDH 208-378 U/L, CHOL

120-199 mg/dL, HDL greater than 55 mg/dL for women, VLDL 7-32 mg/dL, LDL less

than 130 mg/dL, LDL/HDL ratio less than 3.22 mg/dL for women. A normal glucose

level is 70-110mg/dL. Missy was in the normal range for LDH at 220 U/L. She had a

high cholesterol level at 190 mg/dL, but it was still within the normal range just on the

high end. Missy’s HDL was at a low level of 50, and it should be 55 mg/dL or higher.

Her very low LDL was on the high end of the range at 30 mg/dL. LDL levels were

normal but a little high at 110 mg/dL. Missy LDL/HDL ration should have been greater

than 3.22 mg/dL and her level was 2.2 mg/dL. Her glucose level was normal, but again a

little on the high end at 108 mg/dL. Most of Missy’s levels were within the normal

range, but almost all them were on the high end. This can be dangerous because of her

young age and the overweight track that she is on. The longer she is overweight, the

longer her lab values will have to worsen and increase the risk for other related diseases.

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Her albumin levels were on the high end at 4.8 and the normal range is 3.5-5 g/dL. This

may be related to her 24-hour recall of very high protein intake. Her triglyceride levels

were within the normal range of 35-135mg/dL recorded at 114mg/dL. Missy’s ammonia

levels were low recorded at 8umol/L, when the normal range is 9-33umol/L. This can be

a sign of hypertension. (Nelms Case Study Approach 9, LabtestsOnline)

D. Behavioral-Environmental Domain

16. What behaviors associated with increased risk of overweight would

you look for when assessing Missy’s and her family’s diets?

When assessing Missy’s and her families diet and behaviors I would encourage the whole

family to make the lifestyle change to improve their lives. It is almost impossible for a

child to make the lifestyle changes necessary if their parents and other family members

don’t also make the changes. Both Missy’s grandmother and mother have a history of

health problems. Her maternal grandmother has a history of a heart attack, high blood

pressure, and diabetes. Her mother also has a history of diabetes. This is evidence that

the whole family could use a healthy lifestyle change. All of the food is prepared and

purchased by Missy’s parents, so this means that her parents are a crucial part of Missy’s

health.

17. What aspects of Missy’s lifestyle place her at increased risk for

overweight?

Missy’s lifestyle has many components that can lead to an overweight state. The first

thing that is a red flag is her high fat and high calorie diet with a lot of refined grains.

Her diet lacks in fruits, vegetables, and whole grains. Missy’s parents fried almost all of

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the food and added fat such as butter and mayonnaise to everything. Her parents need to

be educated on better ways to prepare food such as grilling or broiling and ways to add

flavor with spices instead of added fat. Another lifestyle problem that Missy is dealing

with is her lack of physical activity. From her doctors report she describes that her

favorite activities include video games and reading. Both of these activities are very

sedentary. To increase Missy’s activity level I would encourage her whole family to

have a set time where they all go outside and play a game together. This will help

motivate Missy and improve her entire families health. The amount that Missy eats also

puts her at risk to become obese. She has two breakfast burritos, two Twinkies, three

pieces of fried chicken, ect. An easy way to reduce caloric intake would be to lower to

one burrito, one Twinkie, and gradually decrease to none.

18. 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 first thank them for being so cooperative and helpful in the process of helping

their daughter become healthier. I would tell them that snacking between meals is not a

bad thing as long as the snack is a healthy option. A smaller meal with snacks in between

is a good way to keep her metabolism going. I would educate them on some of these

options such as an apple with 1 tablespoon of peanut butter, carrots with 2 tablespoons of

ranch, and 6 whole grain crackers with cheese. Whole milk is very high in calories and

fat, so I would advice her to change from whole milk to skim or 1% milk. Popcorn is a

good snack for Missy to have, but instead of microwave popcorn, I would switch to self-

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popped with no added oils or salt. I would not recommend rewarding Missy with dessert

every time she exercised. But if they insisted I would advice them to decrease the size of

the dessert every time and add fruit such as strawberries, blueberries, or raspberries to

increase fruit intake and add nutritional value.

19. Identify one specific physical activity recommendation for Missy.

It is shocking to read in her evaluation that her school discontinued physical education

class with childhood obesity on the rise. I would specially recommend that Missy have

some form of physical activity for 30 minutes per day 5 times a week. After a couple

months she starts to feel better and she can increase to 6 days a week. When she feels

comfortable with this recommendation, she can then increase her time and intensity.

There are many activities that Missy can do. To name a few she can do include biking,

playing soccer with her younger sister, going on a walk with her parents or grandparents,

swimming, or even running around the house at a commercial when she is watching

television. By starting out slow Missy can work her way up without getting discouraged.

IV. Nutrition Diagnosis

20. Select two high-priority nutrition problems and complete PES

statements for each. (NCPT 2014)

1. Excessive energy intake of 4,746 calories as related to diet and lifestyle choices

and lack of education as evidence by a weight history of 115 pounds and BMI of

25

2. Lack of physical activity related to the cut of physical education programs and

person interests as evidence by physical activity report

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NCPT Code

Excessive energy intake

Excessive fat intake

Excessive mineral intake

Excessive carbohydrate intake

Physical inactivity

Food-and nutrition-related

knowledge deficit

Excessive Protein intake

Overweight, Pediatric

NI-1.3

NI-5.6.2

NI-5.10.1 (sodium) 10716

NI-5.8.2

NB-2.1

NB-1.1

NI-5.7.2

NC-3.3.2

V. Nutrition Intervention

21. For each PES statement written, establish an ideal goal (based on

signs and symptoms) and an appropriate intervention (based on

etiology).

1. Excessive energy intake

Goal: Maintain Missy’s body weight by making healthier food options and cutting

out extra desserts. The goal would ultimately be to lower her caloric intake to the

suggest amount of around 2,000 calories. The can be done by gradually eating

one sandwich instead of two and trading dessert for fruit and cool whip. By

making healthier choices in food Missy can also improve the other problem

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macronutrients. I was lastly recommend further education so that both Missy and

her family can learn what proper choices consist of.

2. Lack of physical activity

Goal: The goal is to increase Missy’s physical activity levels from 0 to 30 minutes

5 times a week. I would also recommend Missy’s entire family to exercise with

her to keep her on track and improve their health. After Missy is comfortable

with the 30 minutes 5 times a week, she can then increase to 6 or 7 days a week

and do more intense exercises like jogging.

22. Mr. and Mrs. Bloyd ask about using over-the-counter diet aids,

specifically Alli (orlistat). What would you tell them?

Orlistat is used with an individualed low-calorie, low-fat diet and exercise program to

help people lose weight. Prescription orlistat is used in overweight people who may also

have high blood pressure, diabetes, high cholesterol, or heart disease. Orlistat is also used

after weight-loss to help people keep from gaining back that weight. Orlistat is in a class

of medications called lipase inhibitors. It works by preventing some of the fat in foods

eaten from being absorbed in the intestines. This unabsorbed fat is then removed from the

body in the stool. Some of the side effects include oily spotting on underwear, gas,

urgent need to have a bowel movement, loose stool, fatty stool, pain in rectum, stomach

pain, irregular menstrual periods, headache, anxiety, hives, rash, vomiting, and nausea

just to name a few. I would never recommend a diet pill for a young girl at the age of 10.

The long-term side effects of diet pills can affect a patient negatively for the rest of their

life. Diet pills can inhibit absorption of nutrients need for growth and mono and poly

unsaturated fats needed for brain health. Although studies have shown that Orlistat

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works to decrease BMI, I would recommend that Missy first try to the lifestyle and

physical activity changes first. (MedlinePlus)

23. Mr. and Mrs. Bloyd ask about bypass surgery for Missy. What are

the recommendation regarding gastric bypass surgery for the

pediatric population?

Gastric bypass surgery in the pediatric population is complicated. It is usually not

recommended because of the risk of loss of absorption of important nutrients needed for

the growth of the child. But there certain circumstances that bypass is recommended. A

BMI of 35 or higher and a serious health condition related to obesity such as diabetes,

pseudotumor cererbri, sleep apnea, and severe inflammation of the liver caused by excess

fat, is a circumstance that bypass surgery is acceptable. It is recommended that a child be

on a diet and exercise program for at least 6 months under the care of a physician before

being considered for surgery. That being said I believe that Missy should try the diet and

exercise program for at least 6 months before considering surgery. She also does not fit

the BMI cut off of at least 35. (MedlinePlus Bypass)

VI. Nutrition Monitoring and Evaluation

24. When should the next counseling session with Missy be scheduled?

Missy next counseling session should be 1-2 weeks after her initial session. Her case is

not an emergency but it is important to get Missy educated and changing her life as soon

as possible. If it is longer than a week or 2 Missy and her family may forget about how

important it is for her to make changes. Missy will be going through a lot of new

changes in her life, so it is important that her health team stays on top of it so she doesn’t

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fall of the wagon. Missy should keep a log of her food included the portion sizes, how

the food was prepared, and how she felt after every meal. She should also keep a log of

exercise including type, duration, intensity, and how she feels after the work out. This

will help her stay on track. After the first two meetings, Missy should then meet with the

dietician every two weeks

25. Should her parents be included? Why or why not?

Missy parents should definitely be included in the meetings because they are a crucial

part of Missy’s weight loss success. Her parents need to see how she is progressing and

be educated along with Missy. This will help Missy feel like she is not alone in the

process and that she has support. At Missy’s age, her parents make a lot of decisions for

her when it comes to food and the way it is prepared.

26. What would you assess during this follow up counseling session?

Many different things need to be assessed at the follow up counseling session. I would

first ask Missy how she felt about the new changes in her life and if anything is too much

for her to handle. Then I would weight Missy and recalculate her BMI and caloric needs.

I would then analyze her food and exercise logs (discussed in question 24) to see if she

had been following the recommendations made in the previous meeting. I would show

Missy and her family various resources for education and how to use supertracker.org. I

would assess if her sleep apnea had improved at all because this was her chief complaint.

Lastly, I would analyze Missy new blood work. Though the main focus is on diet and

exercise a good way to gage effectiveness is lab result improvements. I would look at

total cholesterol, LDL, HDL, ammonia levels, triglyceride levels, and LDL/HDL ratio

because there were the items that were of concern.

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Work Cited

Ammonia. (n.d.). LabTestOnline. Retrieved October 14, 2014.

http://labtestsonline.org/understanding/analytes/ammonia/tab/test/

Basics About Childhood Obesity. (n.d.). Centers for Disease Control and Prevention.

Retrieved October 14, 2014.

http://www.cdc.gov/obesity/childhood/basics.html

Cholesterol Levels in Children and Adolescents. (n.d.). About Kids Health. Retrieved

October 14, 2014.

http://www.aboutkidshealth.ca/en/resourcecentres/diabetes/treatmentofdiabetes/

balancingbloodglucosesugar/pages/default.aspx

Cholesterol Levels in Children and Adolescents. (n.d.). Healthy Children. Retrieved October

14, 2014.

http://www.healthychildren.org/English/healthy-living/nutrition/Pages/Cholesterol-

Levels-in-Children-and-Adolescents.aspx

Gavin, M. (2012, October 1). Overweight and Obesity. KidsHealth. Retrieved October 14,

2014.

http://kidshealth.org/parent/general/body/overweight_obesity.html

Nelms, M., & Roth, S. (2014). Medical nutrition therapy: A case study approach (4nd

ed.). Belmont, CA: Wadsworth/Thomson Learning.

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Nelms, M., Sucher, K., Lacey, K., & Roth, S. (2011). Nutrition therapy and

pathophysiology (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning.

Orlistat: MedlinePlus Drug Information. (n.d.). MedlinePlus. Retrieved October 14, 2014.

http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601244.html

Weight-loss surgery and children: MedlinePlus Medical Encyclopedia. MedlinePlus Bypass.

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