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Childhood OverweightChildhood OverweightKayla KmetKayla KmetLora Lee AaronLora Lee Aaron

Rebecca WillisRebecca Willis

Stephanie HunleyStephanie Hunley

Case Study 1Case Study 1Missy Bloyds StoryMissy Bloyds Story

10/28/0910/28/09

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MissyMissy

Client Name:Client Name: Missy BloydMissy Bloyd

Date of Birth:Date of Birth: 10/910/9

Age:Age: 1010Sex:Sex: FemaleFemale

Education:Education: (5th grade) Less than(5th grade) Less than

high schoolhigh school

Occupation:Occupation: StudentStudent

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MissyMissy

Hours of Work:Hours of Work: Regular schoolRegular school

hourshours

Household members:Household members: FatherFather(36), mother (35), sister (5)(36), mother (35), sister (5)

Ethnic Background:Ethnic Background: BiracialBiracial

(African American and Caucasian)(African American and Caucasian) Religious Affiliation:Religious Affiliation: CatholicCatholic

Referring Physician:Referring Physician: D. Null, MDD. Null, MD

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44

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Missys HxMissys Hx Sleep disturbance in last several years- sleepingSleep disturbance in last several years- sleeping

with mouth open, cessation of breathing for 10with mouth open, cessation of breathing for 10

sec, snoring, restlessness, enuresis, morningsec, snoring, restlessness, enuresis, morning

headachesheadaches

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, inFamily Hx:gestational diabetes, type 2 DM, in

mother and grandmothermother and grandmother

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AnthropometricsAnthropometricsHeight: 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 beingAccording to the CDC, overweight in children 2-19 yo. is classified as being

at or above a BMI in the 85at or above a BMI in the 85thth

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

For every five point increase in BMI a person enters a higher bracket ofFor every five point increase in BMI a person enters a higher bracket of

disease risk. The diseases and conditions do not necessarily increase indisease risk. The diseases and conditions do not necessarily increase in

number, but in likelihoodnumber, but in likelihood

Overweight and obesity can come with several co morbidities andOverweight 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 heartdyslipidaemia (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 gouthyperuricaemia (too much uric acid in the blood) which may result in gout

(swelling in feet from deposited uric acid), cancer, reproductive, hormone(swelling in feet from deposited uric acid), cancer, reproductive, hormone

abnormalities, polycystic ovarian syndrome, impaired fertility, low backabnormalities, polycystic ovarian syndrome, impaired fertility, low back

pain, increased anaesthetic risk (loss of sensation or consciousness), andpain, increased anaesthetic risk (loss of sensation or consciousness), and

fetal defects from maternal obesity.fetal defects from maternal obesity.

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Text

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Missys ComplaintMissys Complaint

Weve noticed that Missy appearsWeve noticed that Missy appears

to stop breathing for severalto stop breathing for several

seconds several times a night. Sheseconds several times a night. Sheis really cranky when she gets upis really cranky when she gets up

for school. Her teacher says Missyfor school. Her teacher says Missy

gets very sleepy duringgets very sleepy during

school...She fell asleep in classschool...She fell asleep in class

yesterday.yesterday.

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Missys Nutritional HxMissys Nutritional Hx

General: very good appetite, wideGeneral: 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 vitaminVit/Min Intake: Flintstones vitamin

dailydaily

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AM: 2 breakfast burritos, 8oz whole milk,AM: 2 breakfast burritos, 8oz whole milk,

4oz apple juice, 6oz coffee with 1/4 c4oz apple juice, 6oz coffee with 1/4 c

cream and tsp sugarcream and tsp sugar

LUNCH: 2 bologna and cheese sandwichesLUNCH: 2 bologna and cheese sandwiches

with 1tbsp of mayo, 1 oz package Frito cornwith 1tbsp of mayo, 1 oz package Frito corn

chips, 2 twinkies, 8 oz whole milkchips, 2 twinkies, 8 oz whole milk

24 Hour Recall24 Hour Recall

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AFTER SCHOOL SNACK: Peanut butter and jellyAFTER SCHOOL SNACK: Peanut butter and jelly

sandwich (2 slices enriched bread with 2 tbspsandwich (2 slices enriched bread with 2 tbsp

crunch peanut butter and 2 tbsp grape jelly), 12crunch peanut butter and 2 tbsp grape jelly), 12

oz whole milkoz whole milk

DINNER: Fried chicken (2 legs and 1 thigh), 1 cDINNER: Fried chicken (2 legs and 1 thigh), 1 c

mashed potatoes (whole milk/butter), 1 c friedmashed 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

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DxDx R/O Obstructive Sleep Apnea (OSA) secondary toR/O Obstructive Sleep Apnea (OSA) secondary to

obesity and physical activityobesity and physical activity

OSA:OSA: SleepSleep apnea is a breathing disorderapnea is a breathing disorder

characterized by brief interruptions of breathingcharacterized by brief interruptions of breathing

duringduring sleepsleep.. There are two types ofThere are two types ofsleep apneasleep apnea: central and: central and

obstructive.obstructive.

Central sleep apnea occurs when the brain failsCentral sleep apnea occurs when the brain fails

to send the appropriate signals to the breathingto send the appropriate signals to the breathingmuscles to initiate respirations.muscles to initiate respirations.

Obstructive sleep apnea occurs when air cannotObstructive sleep apnea occurs when air cannot

flow into or out of the person's nose or mouthflow into or out of the person's nose or mouth

although efforts to breathe continue.although efforts to breathe continue.

http://www.medterms.com/script/main/art.asp?articlekey=6177http://www.medterms.com/script/main/art.asp?articlekey=6177http://www.medterms.com/script/main/art.asp?articlekey=6177http://www.medterms.com/script/main/art.asp?articlekey=6177http://www.medterms.com/script/main/art.asp?articlekey=1982http://www.medterms.com/script/main/art.asp?articlekey=1982http://www.medterms.com/script/main/art.asp?articlekey=1982http://www.medterms.com/script/main/art.asp?articlekey=1982http://www.medterms.com/script/main/art.asp?articlekey=6177http://www.medterms.com/script/main/art.asp?articlekey=6177

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Tx PlanTx Plan

PolysomnographyPolysomnography

FBGFBG

HbA1CHbA1C Lipid PanelLipid Panel

Psychological EvaluationPsychological Evaluation

Nutrition AssesmentNutrition Assesment

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Missys AssesmentMissys Assesment

Two Part AnalysisTwo Part Analysis

Testing

Lab Results

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1616

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TestingTesting

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.

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Blood Glucose LevelsBlood Glucose Levels

Missys Blood Glucose Level- 108 mg/dL

Normal Levels- 70-110 mg/dLPrediabetes- 100 mg/dL

Diagnosis of Diabetes- 100-126 mg/dL

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1919

Evaluation of MissysEvaluation of Missys

Blood Glucose LevelBlood Glucose Level Missys Blood Glucose Level- 108 mg/dL -Her current level places her in the higher end of the normal

range and in the prediabetes area.

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

carbohydrates

1919

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Missys Lipid ProfileMissys Lipid Profile

ResultsResultsCholesterolCholesterol 190190

LDLLDL 110110

HDLHDL 5050

TGTG 114114

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Evaluation of MissysEvaluation of Missys

Lipid ProfileLipid Profile Normal Levels vs. Missys Levels Cholesterol-120-199mg/dL 190mg/dL

LDL- 55mg/dL 50mg/dL

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

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Activity LevelActivity Level

Physical Activity Level- sedentaryPhysical Activity Level- sedentary

--Includes reading and playing videoIncludes reading and playing videogamesgames

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Missys Energy

EER for Girls 9 Through 18 Years

EER = TEE + energy deposition

EER = 135.3 (30.8 age [y]) + PA (10.0 weight[kg] + 934 height [m]) + 25 kcal

Where PA is the physical activity coefficient:

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 = 1.31 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)

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

EER= 135.3- (30.8 x10) + 1.0 x (10.0 x 52.3kg + 934x1.45m) + 25 kcal

EER= 135.3- 308 + 1.0 x 1877.3 + 25kcal

EER= 1729.6 kcal

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Missys EnergyMissys Energy

Energy Requirements 1729.6 kcal

Energy Intake -includes high fat and high starch foods with

inadequate fruit and vegetable intake

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

9.06% of total calories High fat foods= 2697 kcals

60.81 % of total calories

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Energy Intake-Energy Intake- High fat and high carbohydrateHigh fat and high carbohydratecontent 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 andDue to her weight andhigh carbohydrate consumption her insulin levels arehigh carbohydrate consumption her insulin levels are

not keeping up with her blood glucose levels, whichnot 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 atElevated levels indicate she is atrisk for developing cardiovascular disease as well.risk for developing cardiovascular disease as well.

Missys AssessmentMissys Assessment

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Missys Diagnosis andMissys Diagnosis and

Treatment PlanTreatment Plan

Missys Nutrition Diagnosis ~ PESMissys Nutrition Diagnosis ~ PES

Excessive energy intake related to energy-Excessive energy intake related to energy-

dense food choices as evidenced bydense food choices as evidenced byestimated energy intake of 4,435 kcalsestimated energy intake of 4,435 kcalsbased on 24 hour recall.based on 24 hour recall.

Physical inactivity related to preference forPhysical inactivity related to preference forsedentary activities as evidenced by reportsedentary activities as evidenced by reportof enjoying video games and reading.of enjoying video games and reading.

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Missys TreatmentMissys Treatment

Missys Nutrition Intervention-Based onMissys Nutrition Intervention-Based on

PES statementsPES statements

1) Excessive energy intake.1) Excessive energy intake.

Goal: for Missy to achieve appropriateGoal: for Missy to achieve appropriate

energy intake levels.energy intake levels.

Intervention: nutrition education for MissyIntervention: nutrition education for Missy

and her parents covering:and 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

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Missys TreatmentMissys Treatment

Missys Nutrition Intervention-Based onMissys Nutrition Intervention-Based onPES statementsPES statements

2) Physical Inactivity.2) Physical Inactivity.

Goal: to increase Missys physical activity.Goal: to increase Missys physical activity. Intervention: encourage her to play moreIntervention: encourage her to play more

outside the house, in addition, weoutside the house, in addition, werecommend that she enroll in an after schoolrecommend that she enroll in an after schoolsports program of her choice (soccer,sports program of her choice (soccer,

basketball, volleyball, swimming, etc) sobasketball, volleyball, swimming, etc) sothat she can be more active and enjoy it.that she can be more active and enjoy it. Also, we recommend Missy get a Wii systemAlso, we recommend Missy get a Wii system

so she can be more active during her screenso she can be more active during her screentime.time.

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Missys MyPyramidMissys MyPyramid

2929

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Missys MenuMissys Menu

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)

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Missys MenuMissys Menu DinnerDinner Fat free milk (skim)Fat free milk (skim)

Chicken, veggies & noodles (cream sauce)Chicken, veggies & noodles (cream sauce)

Raw carrotsRaw carrots

Creamy dressing (ranch)Creamy dressing (ranch)

Wheat roll (part whole wheat)Wheat roll (part whole wheat)

SnackSnack BananaBanana

Lowfat cottage cheeseLowfat cottage cheese

CucumberCucumber

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

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

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Missys MenuMissys Menu

AssessmentAssessment

3232

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Monitoring andEvaluation

Next counseling session for Missy shouldbe scheduled as soon as possible, needsto get appropriate treatment for sleep

apnea and then start Nutrition counselingimmediately.

Her parents should definitely be includedin her counseling sessions, they arepreparing her meals.

In follow up visit, assess short term goalsthat were originally set, these are firststeps to her long term goals. We wouldassess any changes in physical activityand dietary behavior.

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Missys LifestyleMissys Lifestyle

and Our Cultureand Our Culture What put Missy at risk forWhat 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

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Missys Weight LossMissys Weight Loss

OptionsOptions

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

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Missy and Her PeersMissy and Her Peers

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 sedentaryMore physical activity/less sedentary

activityactivity