Depression: Weight Loss Case Study

1. What is depression?

Depression is a clinical disorder that results in someone feeling sad, at loss, angry, or frustrated. The exact cause is unknown but has been linked to a possible chemical change in the brain. Regardless of cause, the result is a feeling of worthlessness, isolation, thoughts of suicide, and distorted views on oneself. It can also result in fatigue and lack of motivation. In order to be classified as depression, the symptoms must affect a person’s daily life over an extended period of time.

Source: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001941/

2. Byrd has decided to treat Ms. Geitl with Zoloft, a selective serotonin reuptake inhibitor (SSRI). Are there any pertinent nutritional considerations when using this medication?

Zoloft should not be consumed with alcohol (this is important to note as Ms. Geitl is a college student who is of age), and should not be taken in combination with certain herbs, including St. John’s wort unless approved by the physician. Vitamin D is also typically taken with Zoloft in those patients with depression.

Source: http://www.naturalnews.com/DrugWatch_Zoloft.html

3. How do serotonin reuptake inhibitors (SSRI’s) work?

SSRI’s are the most commonly prescribed medication for those with depression, as it changes neurotransmitters that communicate between brain cells. They work by blocking the reabsorption of serotonin, and this altered chemical balance helps the brain cells send and receive chemical messages in a manner that has been proven to boost mood, and in turn lessens the symptoms of depression.

Source: http://www.mayoclinic.com/health/ssris/MH00066

 

4. During the diet history, you ask Ms. Geitl if she uses any OTC vitamins, minerals, or herbal supplements. She tells you her mother suggest she try Hypericum perforatum (St. John’s wort) because in Germany it is prescribed to treat depression. Ms. Geitl did as her mother suggester, as it is available without prescription in the United States. What is St. John’s wort?

St. John’s wort is a yellow flowered plant which was discovered to contain chemicals that have medicinal effect. It can be used to treat depression, anxiety, or sleep disorders but can also interact with other medications. It should only be taken with other medications under a physician’s supervision.

Source: http://nccam.nih.gov/health/stjohnswort

 

5. How is St. John’s wort used in the United States?

The flowering tops of this herb are used in preparing teas, tablets, and capsules for medicinal use. In the United States, there is some interest in the public on using St. John’s wort to treat depression (as herbs and natural supplementation has become increasingly popular), but the USDA does not approve St. John’s wort as a treatment of depression as there has not been enough research done on the topic.

Source: http://nccam.nih.gov/health/stjohnswort

 

6. How does St. John’s wort work as an antidepressant?

The flower’s ability to relieve depression is not fully understood. There are studies that suggest an effect on serotonin and dopamine levels in the brain. Some studies suggest the possibility that St. John’s wort may prevent nerve cells in the brain from reabsorbing serotonin (similar to the way Zoloft works). While some studies have attributed the effects on an ability to reduce the levels of protein involved in the body’s immune system.

Source: http://nccam.nih.gov/health/stjohnswort

7. Does St. John’s wort have any side effects?

Side effects include anxiety, dry mouth, dizziness, diarrhea, nausea, fatigue, increased sensitivity to light, headache, confusion, and sexual dysfunction.

Source: http://nccam.nih.gov/health/stjohnswort

8. How is St. John’s wort regulated in the United States?

St. John’s wort is not regulated in the United States, as it is classified as a dietary supplement.

Source: http://www.anxietydepressionhealth.org/st-johns-wort-hypercium.htm

 

 

9. How is St. John’s wort used in Europe?

In Europe, St. John’s wort is widely used as an aid in depression, anxiety, and sleep disorders though it is typically only available through prescription. In Germany specifically, it is prescribed more often than Prozac (a popular antidepressant in the United States and Europe alike). Other uses for St. John’s wort include the treatment of bronchial inflammation, bed-wetting, stomach problems, insomnia, migraines, kidney disorders, hemorrhoids, hypothyroidism, and malaria.

Source: http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMe dicine/HerbsVitaminsandMinerals/st-johns-wort

10. Why do you think people are interested in alternative medicine and herbal treatments?

There is a new push in the market for “organic” and “natural” products because of the use of chemicals and pesticides in the country. I assume that this push is impacting not only people’s perceptions on food but on other chemicals as well. For example, growing up my mom would never let us take medications unless it was absolutely necessary because of the idea that being as close to “natural” and nature as possible is healthier. Herbs are natural and consumers can see what goes into them, while medications have an array of ingredients created in a lab with names that can’t be pronounced. Today’s society is taught that they should know what they are putting into their body. Organic products in the supermarket allow this in respect to food while herbs allow this on the medicinal level.

Source: Cami Gilman

 

11. Because Ms. Geitl is ambulatory, you are able to measure her height and weight. She is 5’11” tall and weighs 160 pounds. You also determine that she is of medium frame. Because Ms. Geitl is from Germany, she is used to reporting her weight in kilograms and her height in centimeters. Convert her height and weight to metric numbers.

Weight: 160 lb/2.2 = 72.72kg

Height: 71in. x 2.54 = 180.34cm = 1.8m

12. Is Ms. Geitl’s recent weight loss anything to be worried about?

Ms. Geitl has had a recent weight loss of five pounds. This loss does not place her in the category of severely malnourished, which is a loss of greater than 10% UBW. However, her weight loss will become a concern if it continues. The cause of her weight loss is depression and therefore, the priority is to treat the underlying cause. Some nutrition education and encouragement to eat may also be necessary, but ideally Ms. Geitl will begin to eat more regularly when her depression subsides.

Source: Cami Gilman

 

13. Because Ms. Geitl is alert and cooperative, you ask her to complete a Patient-Generated Subjective Global Assessment (PG-SGA) of Nutritional Status. How would you score her?

Sections	Score
Box 1	1
Box 2	1
Box 3	1
Box 4	3
Weight loss section (Table 1)	0
Disease section (Table 2)	0
Metabolic section (Table 3)	1
Physical section (Table 4)	0
Total	7

14. Using Appendix 1, how would you triage nutritional intervention?

Ms. Geitl’s triage point score is about a 2-3, meaning that education is the primary intervention. This can be done by a dietician, nurse, or clinician. If weight loss progresses so much that her triage score becomes a 4-8, a more aggressive intervention will need to be implemented and this would include a team approach that would include a dietician in conjunction with a nurse or physician.

15. What methods are available to estimate Ms. Geitl’s energy needs?

Several acceptable methods exist when estimating one’s energy needs. These methods include the Mifflin-St. Jeor formula, the Harris-Benedict equation, the Quick Estimate equation, and the WHO (World Health Organization) equation. Some take into account different factors, but all are good estimations on caloric needs.

16. Calculate Ms. Geitl’s basal energy needs using one of the methods you listed in Question 15.

Mifflin-St. Jeor: 10 x wt (kg) + 6.25 x ht (m) – 5 x age (yrs) – 161

10 x (72.72) + 6.25 x (180.34) – 5 x (20) – 161 = 1,593 = 1,500-1,600 kcal/day

17. What is Ms. Geitl’s estimated energy expenditure?

EER: 354 – 6.91 x age + PA x (9.36 x wt + 726 x ht)

354 – 6.91 x (20) + 1.12 x (9.36 x (72.72) + (1.8034))

= 2,287 kcal or 2,200-2,300 kcal/day

Protein (15%): 2,287 x .15 = 343.125 / 4 = 86 grams

Fat (25%): 2,287 x .25 = 571.75 / 9 = 64 grams

Carbohydrates (60%): 2,287 x 1,372.8 / 4 = 343 grams

18. Evaluate her diet history and her 24-hour recall. Is she meeting her energy needs?

According to her 24-hour recall in particular, Ms. Geitl has consumed about 650/700 kcals consisting of 12g total fat, 88g carbohydrates, and 52 grams of protein. Her overall diet history seems to have a similar dietary pattern. You can see above that the recommended dietary intake for someone Ms. Geitl’s height, weight, and age. This includes at least 2,200 kcals per day and 86 grams of protein, 64 grams of fat, and 343 grams of carbohydrates. Therefore, she is not meeting her energy needs.

Source: My Fitness Pal iPhone Application

 

19. What would you advise?

I would advise Ms. Geitl to consume three meals and three snack each day. Each meal and snack should include some form of each macronutrient (carbohydrate, protein, and fat). I would emphasize the importance of her nutritional health as it may also be contributing to her depression. If her body was better nourished, she may get some of her energy back and sleep better. I would also recommend a multivitamin that had vitamin D and talk to her about different foods that are good sources of vitamin D, because of the drug-nutrient interaction of zoloft.

20. List each factor from your nutritional assessment and then determine an expected outcome from each.

Assessment Factor	Expected Outcome
Inadequate caloric intake	Increase caloric consumption by ensuring three full meals each day with snack in between. These meals should be nutrient dense, and this will stop the weight loss which may be in part contributing to depressive symptoms.
Inadequate Fat intake	Increase fat intake. Fat-soluble vitamins A,D,E, and K are most likely not being properly absorbed as they need fat in order to do so. Focus on good fats from nuts, seeds, fish, and olive oils.
Inadequate Protein intake	Increase protein intake so prevent continued muscle wasting. This should be done via meat products with good fats as well as protein-rich plant sources (beans, nuts, soy).
Low Vitamin D intake	Increasing vitamin D intake through a multivitamin as well as a natural sources will help with depressive symptoms and also aid in the drug’s antidepressant effects.

21. What is your immediate concern regarding this patient’s use of St. John’s wort?

Initially, my concern was a drug-herbal interaction or overdose if taken with the SSRI antidepressant Ms. Geitl was prescribed. After more research, I was also concerned with the possibility of it getting in the way of protein absorption as Ms. Geitl is already at risk of becoming malnourished.

22. Review the initial note written for this patient. Is this progress note appropriate? Is it complete? Any errors? Any omissions?

The initial note written for Ms. Geitl was no appropriate – incomplete and had some errors and omissions in it. Overall, I prefer the ADIME method. In the subjective data, the total number of kcal and protein should have been included from the diet history and 24-hour recall. Though you can guesstimate that the patient is not eating enough, an exact number is necessary in order to show just how far off the patient is. Also omitted was the patient’s alcohol consumption – which is essential in knowing whether or not to educate the patient on consuming alcohol safely if she does choose to do so, and the importance of not taking her medications when consuming alcohol. Also omitted was religious background which may be important if there are dietary restraints based on religious beliefs. Objective data was also omitted. The conversion of metric height and weight were not there (which is important as this patient is an international student) and are essential for understanding. Also omitted was the gender of the patient, temperature, pulse, blood pressure, respiration rate, medical diagnosis, and current medical care.  There was also no PES statements which are essential in the approach to a nutrition i

Case Study: Childhood Obesity

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 of childhood obesity: biological (genetics and pathophysiology); behavioral-environmental (sedentary lifestyle, socioeconomic status, modernization, culture, and dietary intake).

As far as biology, genetics do have some impacts on obesity rates. Certain genetic characteristics can cause a slow metabolism and similarly, genes decide the number of fat cells a person has. However, this can be controlled as evidence has shown that physical activity can override the predisposition for a high BMI and wide waste circumference. This being said, there are some exceptions in the case of rare genetic mutations that can lead to severe obesity but again, this is very rare. Medications and certain medical conditions (such as hypothyroidism and Cushing’s disease) may also cause weight gain that leads to overweight and obesity. The pathophysiology of overweight and obesity is linked to the hypothalamus and pituitary gland in the brain. Leptin and ghrelin are the hormones that control hunger and satiety. Leptin is released by fat cells and is responsible for decreasing appetite. When fat storage rises, leptin levels are to rise as well to tell the body that there is an excess in food and consumption can fall. Not only does leptin influences fat storage but it also influences insulin resistance. One of the most commonly accepted theory is that those who are overweight and obese have low levels of leptin and therefore are always hungry.

When looking at behavior and environment, there are many different aspects that can impact a child’s weight. One of the biggest factors is that of a sedentary lifestyle, especially watching television. Television is full of ads and the act of watching it is often associated with unhealthy snacking, while not calories are being burnt doing this activity. Socioeconomic status has also been associated with an increased risk of overweight related to the increased prices of whole and natural foods and the decreased price in those “fast” foods which most often contain added salt, fat, and sugar. This can be seen statistically: 34.7% of those below the poverty level are obese while only 28.7% of those 200% or higher above the poverty level are obese. New technology has also impacted the rates of obesity. Packaged foods and fast/convenience foods have become a daily ritual as they are inexpensive and easily accessible. These foods often have high levels of excessive dietary fat, while drinks now have an excess of added sugar to match consumer demands. Portion sizes continue to grow as well.  Culturally, eating less often (2-3 meals per day) is becoming a norm while research shows that those who eat smaller meals throughout the day are associated with lower weight. When looking at different ethnic and racial backgrounds, the prevalence of obesity and overweight is higher in non-white populations. This has little to do with the slight alteration in genetics among the races, but correlates to the socioeconomic separation of race and ethnicity.

On the Global scale, obesity and overweight has become an epidemic known to the World Health Organization as “Globesity”. Though is started in only developed nations (United States, Canada, European Nations), underdeveloped nations are also starting to a greater prevalence but the difference is that the obesity and overweight are often also coupled with malnutrition. The social norm of fast food and a fast pace lifestyle is spreading. Though there are external influences, it all comes down to education and choice – the nutritional knowledge to make healthier choices. This is why obesity often is associated with feelings of guilt, anxiety, and low self-worth. Resulting depression can lead to binge eating and low self-esteem.  On the other side of the spectrum, this low self-esteem and distorted body image is also increasing the prevalence of eating disorders including binge-eating disorder but also anorexia nervosa as well as bulimia nervosa.

Source(s): An array of articles from an accredited site: www.obesity.org

2. Describe health consequences associated with an overweight condition. Describe how health consequences differ for an overweight versus an obese condition.

According to the CDC, there are numerous health risks associated with having a BMI of overweight or obese. These include several immediate threats as well some long term threats. In children, the immediate risks include a greater likelihood of developing high blood pressure and high cholesterol which are both risk factors for cardiovascular disease. There is also an increased risk of impaired glucose intolerance, insulin resistance, and the development of type II diabetes. Other immediate symptoms include breathing problems, sleep apnea, asthma, joint problems, and musculoskeletal discomfort. As BMI (or the BMI percentile for children of the same age and sex) increases, the likelihood and severity of these complications increase. For example, type II diabetes is three times as prevalent in those who are classified as obese compared to those classified as having a normal BMI. Also associated with Obesity is increased social and psychological problems including low self-esteem, resulting from discrimination. Children who are obese as children are more likely to become obese adults, and are also more likely to develop complications later on such as heart disease, diabetes, and even some cancers.

Source(s): www.cdc.org

3. Missy has been diagnosed with obstructive sleep apnea. Define sleep apnea. Explain the relationship between sleep apnea and obesity.

Obstructive sleep apnea syndrome (OSAS) is a breathing disorder in which one or more pauses occur that can last anywhere from a few seconds to a minute, and can occur up to 30 times in an hour. This can be related to low blood oxygen concentrations and sleep disturbance. There are four primary related causes, and one of those causes is obesity. In this population, excess fat creates an excess of soft tissue lines the throat that can fall down and block the airway. In the case of obese children, OSAS can occur anywhere from early infancy to late childhood. As the epidemic of obesity spreads, this particular cause is now perhaps the most prominent cause of OSAS in children.

Source(s): American Academy of Pediatrics. Clinical practice guideline: diagnosis and           management of childhood obstructive sleep apnea syndrome. Pediatrics 109: 704–712, 2002.

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 is not always the primary goal in the overweight pediatric population. Weight loss goals are decided on several different circumstances including age, BMI percentile for children of the same height and weight, and the presence of medical complications. Very specific guidelines have been set by the Academy of Nutrition and Dietetics for deciding what approach to use. In the age group of 2-5 year olds, weight loss is only appropriate if the BMI percentile is at or above the 95^th percentile and serious medical complications are present, in which case 1lb. may be lost per month. In the age group of 6-11, weight loss can occur at a rate of 1lb/month only if the child is between the 95^th and 99^th percentile. If a child age 6-11 is above the 99^th percentile then a maximum loss of 2lbs/week is appropriate.  In the age group of 12-18 year olds, a maximum loss of 2lbs/week is appropriate for any child who is categorized in the 95^th percentile of above. Weight loss is not appropriate unless the conditions mentioned above are present as weight loss may affect growth. If weight loss is not appropriate, a specific nutrition prescription is to be used in order to simply stabilize weight and prevent further gain.

Source(s): Weight Goals and Intervention Stages, According to Age and BMI Categories – http://pediatrics.aappublications.org/cgi/content-nw/full/120/Supplement_4/S164/T8

5. What would you recommend as the current focus for nutritional treatment of Missy’s obesity?

Missy’s nutritional treatment would be multicomponent as treatments with multiple aspects are proven to be more successful. This would include nutrition counseling and diet, an increase in physical activity, a decrease in sedentary behaviors, and parent participation. The first aspect, nutrition counseling and diet would focus on behavioral interventions. Missy would learn how to self-monitor her diet and physical activity, cue-elimination, stimulus control, goal-setting, modeling, and positive reinforcement. These are all intertwined amongst the other aspects and would be simplified so Missy can easily understand it. Self-monitoring would also be made fun by using bright pictures and colors to get Missy excited about keeping track and changing her eating habits. Cue-elimination would involve decreasing the amount of time in front of the television – a common cue for unhealthy snacking – and identifying any other cues that Missy commonly faces.

Goal-setting would include incorporating more fruits, vegetables, and low-fat dairy products into Missy’s day. This would also include striving towards the guidelines for physical activity which is 60 minutes of more daily for children and adolescents. The focus would be on finding activities that excite Missy, whether that is riding a bike or going for walks with Mom and Dad. Modeling would especially include Mom and Dad. While Missy is trying to alter her diet, Mom and Dad will have to supply healthy options in the home (to pack for school, and have as snacks) as well as start providing more nutritious meals lower in fried foods and excess sugar. The food supply in the home will have to be altered to having less processed, high fat, high sugar foods and turn to more fresh and lean products. And of course, success should be rewarded. As healthy options are made, rewards that do not involve food should be used. For example, Missy may put marbles into a jar and once the jar is full the family will go on an outing together.

Missy, as well as the parents, will also meet with the dietician routinely until the sleep apnea has improved. Adjustments will be made as necessary throughout the treatment.

Source(s): Bauer, K.D., Liou,D., Sokolik, C. (2012), Nutrition counseling and education skill  development, (Second edition). Belmont, CA: Wadsworth.

6. Overweight and obesity in adults is defined by BMI. Children and adolescents are often-times 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.
7. The CDC uses growth charts including BMI for age and sex percentiles. They have these charts for ages 2 through 19. Unlike adults, body composition changes in boys and girls are different ages. Therefore, these charts reflect the average boy and girl at that age, and the “healthy” BMI ranges for that age.

Overweight: BMI at or above the 85^th percentile and below the 9^th percentile for children of the same sex and age.

Obese: BMI at or above the 95^th percentile for children of the same sex and age.

2. The American Academy of Pediatrics uses a slightly different definition. An ideal body weight is given for boys and girls at certain ages and height. This is based on the percentile chart used by the CDC. The difference is that this organization looks towards ideal body weight percentages to decide the risk of health complications from severe obesity.

Severe Obesity: more than 20% above the IBW, or 120% of IBW.

3. The American Heart Association uses the same approach as the CDC when categorizing overweight and obese in children.

Overweight: BMI at or above the 85^th percentile and below the 9^th percentile for children of the same sex and age.

Obese: BMI at or above the 95^th percentile for children of the same sex and age.

Source(s): Accessed at: www.cdc.gov, www.aap.org, www.heart.org

 

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?

115lb / 2.2 = 52.27 kg             57in / 0.254 = 1.448 m

1. BMI = weight (kg) / height (m)²

= 52.27 / (1.448)²

BMI = 24.94 à 97^th percentile à Obese

2. Ideal body weight (Leffler Formula): 76.25 lbs. – this method was very complex and done on a “smart” calculator. I don’t agree with using this method in practice as it does not include stature or muscle mass, but simply height, age, and sex.

(115lb – 76.25lb) / 115lb = 134% IBW à Severe Obesity

3. The same as #1. (see above)

Regardless of which source was used, Missy is classified as either obese or severely obese. However, because I don’t agree with Leffler’s formula, I would classify Missy as being obese.

Source(s): Academy of Nutrition and Dietetics. Evidence Analysis Library.

Accessed at: http://www.andeal.org/template.cfm?template=guide_summary&key=1457

8. If 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.
9. This first method is an adaptation of the estimated energy requirements similar to that of the Mifflin St. Jeor equation, and represents the maintenance of overweight and obese children between the ages of 3 and 18. However, this equation has had some controversy as it does not encourage weight loss but more so allows weight maintenance in overweight and obese children.

Female TEE = 389 – 41.2 x Age [y] + PA x (15 x Wt [kg] + 701.6 x Ht [m])

= 389 – 41.2 x [10y] + 1.2 x (15 x 52.27kg) + 701.6 x [1.448m]

= 389 – 412 + 941 + 1,015

= 1,933.9 à 1,800 to 2,000 kcal per day to maintain

2. The second option, the one that I would use, would start with the TEE found above, but be adjusted based on progress. Also, by looking at not only the number of calories consumed each day but the type of calories consumed – the amount of fat, simple carbohydrate or complex carbohydrates, lean protein, and calories consumed through liquids. If Missy’s weight continued to increase after putting her on a 1,800 calorie diet then I would adjust downward. If Missy’s weight dropped too quickly on a 1,800 calories diet then I would recommend altering towards the higher end of the 2,000 calories. I know this is not a calculated method but in the case of childhood obesity, there are so many factors that must be considered. It is best to compare guidelines to each case individually and adjust based on results.

Source(s): Eatright.org

Accessed at: http://www.andeal.org/template.cfm?template=guide_summary&key=1457

9. Dietary factors associated with increased risk of overweight are 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.

Many items in Missy’s 24-hour recall were high in fat: breakfast burritos, bologna, cheese, mayo, fritos, twinkies, peanut butter, fried chicken, mashed potatoes with butter and whole milk, and fried okra. Some of the drinks were also high in fat: whole milk and cream. These, along with the other beverages were very calorie dense: the whole milk and cream, apply juice, sweet tea, and coca-cola. Moderation was another issue as Missy did not just consume some of each of these items but she consumed a lot of each. Portion sizing is another aspect that Missy will have to be educated on.

Micronutrient Breakdown:

Total kcal: 4,470    (3,432 from food – 1,038 from fluids)

Protein: 152g à 13%

Fat: 220g à 38%

Sat. Fat: 46% à about 100g

CHO: 477g à 49%

Source(s): fitday.com

10. Increased fruit and vegetables intake is associated with decreased risk of overweight. Using Missy’s usual intake, is Missy’s fruit and vegetable intake adequate?

Missy’s fruit and vegetable intake was not adequate. Missy consumed mainly starchy vegetables of those high in saturated fat, and fruit products high in sugar. Her only vegetables were mashed potatoes and fried okra while her fruit intake consisted of jelly and apply juice. The recommendation for girls age 9-13 is about 2 cups of vegetables per day and 2 cups of fruit per day. These vegetables are preferably not including those high in starch and excess fat like the ones she consumed.

Source(s): Ross, Insel Turner (2009). Discovering Nutrition.

11. Use the MyPyramid Plan online tool (MyPlate) to generate a personalized MyPlate for Missy. Using this eating pattern, plan a 1-day menu for Missy.

I tried to incorporate things that were similar to some of Missy’s usual choices while still altering quite a lot. Therefore, I incorporated a sandwich with low fat mayo, apple juice, chicken on the bone, and mashed potatoes.

Breakfast: 1 cup skim milk

½ cup whole grain oatmeal

½ banana

Snack: ½ cup low fat yogurt

¼ cup strawberries

Lunch: 1 Turkey Sandwich (2 oz turkey, 2 thin slices whole wheat bread, low-fat mayo)

1 oz. pretzels

½ cup carrots w/ low-fat ranch

4 oz. Apple Juice (or apple)

Snack: 2 stalks celery

1 tbsp. peanut butter

Dinner: 3 oz. baked chicken (on the bone)

½ cup mashed potatoes (made w/ skim milk)

½ cup broccoli

½ cup skim milk

12. Now enter and assess the 1-day menu you planned for Missy using the MyPlate tracker tool. Does your menu meet macro- and micronutrient recommendations for Missy?

Yes, Missy consumed 5 oz. of grain (3 whole grain), 2 cups of vegetables (a variety of types), 1.5 cups of fruit (mostly fresh and not juice), 3 cups of calcium, and 5 oz. of (mainly lean) protein.

Source(s): myplate.gov

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

Dr. Null ordered the lipid profile blood test for two reasons: to look for signs of diabetes primarily but also to make sure Missy’s state of overweight has not impacted the function of her heart. Having a family history of diabetes, it is essential to make sure Missy has not developed diabetes as well and if she has, she needs to begin proper treatment. Evidence of diabetes would be seen in Missy’s blood glucose levels. Dr. Null will look at lipid levels and lipoprotein levels to analyze Missy’s cholesterol levels and triglycerides. Though Missy is young, high cholesterol is associated with childhood obesity and can cause problems with her heart later on if not taken care of properly.

Source(s): Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

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

Abnormal lipid and glucose levels for pediatric populations are greater than 140mg/dL and great than 110 mg/dL, respectively.

Source(s): Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

 

15. Evaluate Missy’s lab results.

Most of Missy’s lab results are within normal ranges but are often on the higher side or the lower side of normal. Her LDL cholesterol levels were a bit on the high end while her HDL was a bit low. Through her new diet, however, these levels should drop. This is something to monitor as she progresses over the next few months. Her glucose levels are on the high end which puts her are an increased risk for diabetes. Other things to note are low calcium levels. The guidelines of her nutritional intervention, as well as just weight loss in general, should help Missy’s lab values improve. There will be a great focus on decreasing the amount of sodium and trans fat in her diet, as well as increasing the amount of fruits, vegetables, and low fat dairy products.

16. What behaviors associated with increased risk of overweight would you look for when assessing Missy’s and her family’s diet?

The first thing I would look for are signs of socioeconomic class and how affordable healthy foods are to the family. I would then look at who does the shopping in the family and what foods are typically found in the kitchen. I would look at how much of this food is processed food high in fat, salt, and sugar versus how much of this food is fresh fruits and vegetables, lean proteins, low-fat dairy products, and whole grain. Perhaps there is very little food in the kitchen. If money is tight, finding less expensive healthy options would be part of the nutrition education aspect for the parents. Then I would look at the parents and their jobs – who does the cooking? Is there time to cook? I would ask the family about what they do during their free time – do they watch television or do they take their kids to the park? All are very important when deciding how plausible it is to help Missy work towards a healthier lifestyle.

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

First of all, Missy’s sedentary lifestyle puts her at risk for overweight – the television is perhaps the biggest reason. Watching television is one of the biggest contributors to overweight and obesity as it encourages unhealthy snacking. Also, having no physical education and not being physically involved in any sort of athletics are other risk factors. Her consumption of foods high in saturated fat, beverages with added sugar, and lack of fruits and vegetables. Also, being non-white increases Missy’s likelihood of being overweight.

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 am a firm believer in snacking! I would tell Missy’s mother to let her snack and even encourage it. It is the choice of snack that matters though. Snack are a way of sneaking in extra nutrients throughout the day – fruits, vegetables, lean protein. I would tell Missy’s mother to encourage snacking but help her choose what to eat and to eat these snacks in moderation. Also, I do not believe in using food as a reward – I think that puts a sort of emotional tie on food and food should be used as a way of sustaining oneself – not as a form of reward, though having treats on occasion is not a bad thing. I would tell Missy’s mom that it is a great idea to come up with a reward system but to focus on something other than food. For example, maybe Missy can put a marble in a jar every time she exercises. When that jar is full, the family can use it as an excuse to go to a water park or perhaps get ice cream. This way, the rewards aren’t daily but Missy can aim for long-term goals.

Source(s):

19. Identify one specific physical activity recommendation for Missy.

This change for Missy is going to impact everyone in her household, so to keep the positive and supportive team together, I am going to recommend that Missy and her family go for a 60 minute walk every night after dinner instead of watching television.

20. Select two high-priority nutrition problems and complete PES statements for each.
21. Physical inactivity R/T a lack of physical education at school AEB a reported low activity level.
22. Excessive saturated fat intake R/T consumption of fast and convenience foods as well as a lack of knowledge on this topic AEB patient’s 24-hour recall resulting in about 100g saturated fat intake.

21. For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on etiology).
22. Goal: Increase physical activity by finding activities that Missy enjoys – walking, riding bike. Also encourage Missy to get involved in some sort of after-school program that involves physical activity. She should be getting 60 minutes of some form of activity each day.
23. Goal: decrease Missy’s saturated fat intake to less than 15 grams per day. This can be done through educating her on decreasing the number of processed and high fat foods in her diet, and replacing them with fresh fruits, vegetables, and low-fat dairy products.

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

The purpose of Alli is to block the absorption of fat. The current recommendations for Orlistat is to not give over-the-counter to anyone under the age of 18. It commonly causes disturbance in the gastrointestinal tract leading to steatorrhea – oily stool. This is because the fat is not being absorbed into the body. However, fat is an essential nutrient especially for growing children. It helps in the absorption of fat-soluble vitamins A, D, E, and K. These are essential at this point in Missy’s life. Also, weight loss is something that Missy should be able to do without any extra help. Making small changes in her diet will have a huge impact on her health. These changes will not only help with her sleep apnea and other health issues but it will also help her confidence when she knows that she can be healthy without the help of diet aids.

Source(s): FDA approves orlistat for over-the-counter use. FDA News February 7 2007. Retrieve from http:www.fda.govbbstopicsNEWS2007NEW01557.html

23. and Mrs. Boyd ask about gastric bypass surgery for Missy. What are the recommendations regarding gastric bypass surgery for the pediatric population?

Weight loss surgery such as gastric bypass surgery is something considered in morbidly obese children over the age of 13. Any sort of weight loss surgery is not something recommended for those under the age of 13. Also, the primary goal is not lose weight but to create a healthy lifestyle for Missy. She needs to learn how to make healthy food choices and incorporate exercise into her daily routine as these are habits that she can take with her for the rest of her life. This can improve her overall quality of life, and that is the real goal.

Source(s): Same as #4

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

Because there was some question about the accuracy of Missy’s TEE, I would schedule to meet with her one week after the initial appointment and then after that, meet every other week to assess the rate at which weight loss was occurring for the first few weeks. Losing weight too quickly could stunt her growth, but she also needs to lose some in order to help with medical complications. Once we know that Missy’s energy intake is following our course of action, these counseling sessions can be more spread out. It is also important towards the beginning to make sure Missy, as well as her parents, are following the guidelines to help with her sleep apnea. This is why I would meet with her one week later at first. Missy and her family will be implementing many changes, and having the support and guidance is essential.

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

I would definitely include her parents. Missy is only ten years old and although I would be able to teach her some things that she needs to know, a lot of it is going to take time to learn. Her parents are going to have to be teachers as well who will guide her through the process of change. Keeping a journal may be difficult at first, or knowing how to incorporate fruits, vegetables, and low-fat dairy products. Also, the parents are the ones who do the grocery shopping so coaching them on how to shop with Missy is essential – they will be the ones showing her how to select healthy options but overall, they will be the ones providing this food for her.

Based on the 24-hour recall Missy gave, her parents have a huge impact on what is in the house and what Missy consumes. The parents will have to make just about as many changes as Missy through this process if they want Missy’s health status to improve.

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

During the follow-up session, I would look at Missy’s weight and lab values first. This would include what was mentioned above to check for progress in cholesterol levels as well as blood glucose levels for signs of developing diabetes. Then I would talk with Missy and her family about her journal that she was to keep with all of her food and exercise in it. We would look at areas that she struggled in and work together to find way to overcome these obstacles. I would talk to her more about portion sizes and learning to prepare her own food. We would also look at her exercise progress. Every step forward will be celebrated, and new goals will be set. If there are steps backward, no fret, just continue to set new goals.

Resources

Bauer, K.D., Liou,D., Sokolik, C. (2012), Nutrition counseling and education skill

development, (Second edition). Belmont, CA: Wadsworth.

Fitday.com (2014). Retrieved from: http://www.fitday.com/app/log/

Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

Ross, Insel Turner (2009). Discovering Nutrition.