Pediatric Obesity, A case study

1. PEDIATRIC OBESITY:
A CASE STUDY
VALERIE AGYEMAN
UMD DIETETIC INTERN
MAY 5TH, 2016

2. OBJECTIVES
 Discuss pediatric obesity epidemic
 Utilize ADIME in a pediatric weight management intervention
 Review the RD’s role in pediatric obesity treatment
 Discuss the importance of motivational interviewing

3. CHILDHOOD OBESITY EPIDEMIC
 There is an association between the rising prevalence of childhood
obesity and a corresponding increase in:
 Diabetes Mellitus
 Hypertension
 Dyslipidemia
 Nonalcoholic fatty liver disease
 Hypertension
 Cardiovascular disease
 Joint pain and muscle/skeletal discomfort
 Social and psychological problems
 Breathing problems
http://guardianlv.com/wp-content/uploads/2014/02/Childhood-Obesity-Determining-Factors-Examined-in-New-England-Study1.jpeg

4. INITIAL TREATMENT FOR PEDIATRIC OBESITY
 Diet
 Exercise
 Behavioral modification
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5. PATIENT OVERVIEW
13 year old Hispanic female
Referred by Pediatrician
Reason for visit:
Weight management and Lab abnormalities

6. ASSESSMENT

7. PAST MEDICAL HISTORY
 Vitamin D deficiency:
Takes vitamin D prescribed by Primary Care
Physician

8. ANTHROPOMETRICS
Weight (kg) 83.3 kg Weight-for-age 98%ile
Height (cm) 161.4 cm Height-for-age 56 %ile
BMI (kg/m2) 31.97 BMI/age 98.28%ile
IBW (kg)
@85%ile BMI/age
60.7 kg %IBW 137%
Initial RD Visit 4/26/16

9. STATURE FOR AGE & WEIGHT FOR AGE
Stature-for-
age:
 161.4 cm
 56th %ile
Weight-for-
age:
 83.3 kg
 98th %ile

10. BMI-FOR-AGE
 BMI 31.97
 BMI for
age
98th %ile

11. FOOD AND NUTRITION RELATED HISTORY
 Mother does not cook regularly at home
 Healthy foods such as vegetables are not readily available in the home
 Dad purchases meals from fast food restaurants up to 3 times per week
 Admits to eating large portions
 Consumes candy, sweets, chocolates
 Drinks a lot of soda and sweetened beverages
 Family eats fried foods at home
 Eats fruit/vegetables only sometimes
 Not very physically active

12. PERTINENT LABS FROM 2/29/16
 Total Cholesterol 142
 TG 91 H
 HDL 46
 VLDL 18
 LDL 79 H

13. 24 HOUR RECALL
Breakfast 7:00 am 1 plate of white rice and
meatballs with Kool-Aid
Lunch 12:00 pm School lunch: 5 chicken
nuggets, fruit cup and
chocolate milk
Snack 3:30 pm One bowl of Fruit Loops
cereal with 2% milk
Dinner 9:00-9:30 pm
After waking from an
unintentional nap
Fruit Loops cereal with 2%
milk
One plate of white rice

14. PHYSICAL ACTIVITY
 Soccer Team on Thursdays from 3:30-5 pm
 No PE class this school year
 Per Father, does not like to engage in activities with him
and sister when asked
 Screen time: 1 hour of phone usage (10-11 pm)

15. ASSESSMENT DIAGNOSES
Obesity due to excess calories
Mixed hyperlipidemia
Elevated hemoglobin A1c
Insulin resistance

16. DIAGNOSIS
(NC 3.3) Obesity, pediatric related to self-
monitoring difficulty, excessive energy
intake, physical inactivity as evidenced by BMI
of ~32 and BMI-for-age in the 98%
percentile.

17. POSSIBLE BARRIERS TO WEIGHT MANAGEMENT
 Family:
 Lack of support from entire family
 Food choices purchased for the home
 Lack of family role modeling
 Mother does not cook regularly/healthy foods at home
 Father purchases fast foods up to 3 times per week due to convenience
 School
 Less healthy school meals
 eating behaviors of peers
 Individual characteristics:
 Patient stuck in unhealthy routine
 Not motivated to be active

18. SISTER VS. SISTER
G.D
 13 years old, Obese
 Vitamin D deficiency
 Elevated LDL, TG, and HbA1c
 Not motivated to be active
 Large portions
 PA once a week for 1.5 hours
 Consumes fried food purchased by
dad
 Eats out regularly with friends
K.D
 11 years old, Overweight
 Vitamin D deficiency
 Elevated total cholesterol, LDL
 Enjoys physical activity
 Large portions
 Consumes fast food purchased by
dad
 Motivated to make lifestyle changes

19. Nutrition intervention

20. ESTIMATED ENERGY REQUIREMENTS
 MSJ: -161 + 10 (60.7 kg) + 6.25 (161.4 cm)- 5 (13 y.o) = 1403
kcals/d
 1403 kcals x AF 1.3 (Ambulatory)= 1800 kcals/d
 EER for Sedentary (13 years old) ~1500 kcals IBW used
 Protein: 0.95g x 83.3 kg = 79 g/d
 DRI for 9-13 years old and ABW used
 Fluid:1500 ml + [(83 kg-20 kg)] x 20= 2,760 ml/d
 Holiday Segar Method and ABW used

21. NUTRITION COUNSELING APPROACHES
 Multidisciplinary treatment of pediatric obesity
 Nutrition Assessment – 24hr recall + suggestions for change
 Tailor behavior intervention to Stages of Change
 Motivational Interviewing w/ RD
 Self- Monitoring
 Goal Setting
 Diet intervention
 Allow the client to choose or suggest the behavior change

22. NUTRITION EDUCATION
 Mixed Hyperlipidemia
 Healthier cooking preparation methods
 Increasing high fiber foods
 Limiting fried/fast foods
 Elevated hemoglobin A1c
 Low glycemic, high fiber/whole grain foods
 Avoiding refined grains and added sugar
 Insulin resistance
 Limit added sugars and refined grains
 Physical activity

23. HANDOUTS
 Low carb snacks
 Healthy breakfast options
 List of low sugar foods
 High fiber cereals
 MyPlate method
 Goal sheet

24. GOAL SETTING
1. Will only drink water and white, low fat milk at home
2. Will eat a healthy option for breakfast every morning
3. Choose fresh fruit and vegetable sides for lunch at school and in between
meals
4. Limit eating out/fast food to only one meal per week still choosing only
water to drink
5. Increase exercise to 1 hour of walking to and from the park and being
active while there
6. No naps after school, find ways to be active instead

25. MOTIVATION TO CHANGE ON A SCALE FROM
1-10
10 !!!!!!!!!!!!!!
https://doctormarialuque.files.wordpress.com/2014/11/bigstock-
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26. Monitoring & Evaluation

27. MONITORING AND EVALUATION
 Follow up in 2 months:
 Weight & weight-for-age
 Height & height-for-age
 BMI & BMI-for-age
 Types of food/meals
 Amount of food
 Physical Activity (type, duration, frequency)
 Labs

28. Questions?

29. REFERENCES
 Michalsky M.P, Inge T.H, Simmons M, Jenkins T.M, Buncher R, Helmrath M, Brandt M.L, Harmon C.M,
Courcoulas A, Chen M, Horlick M, Daniels S.R, Urbina E.M. Cardiovascular Risk Factors in Severly Obese
Adolescents. JAMA Pediatrics. 2015; 169 (5): 438-444.
 The N.S, Suchindran C, North K.E, Popkin B.M, Larsen P.G. Association of Adolescent Obesity with risk of severe
obesity in adulthood. JAMA. 2010; 304 (18): 2042-2047.
 Ross MM, Kolbash S, Cohen GM, Skelton JA. Multidisciplinary treatment of pediatric obesity: nutrition
evaluation and management. Nutr Clin Pract. 2010;25(4):327-34.
 Academy of Nutrition and Dietetics (n.d.). Overweight and Obesity. Retrieved May 2nd, 2016 from
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=16997&ncm_heading=Nutrit
ion Care&ncm_content_id=79432#DiagnosticTests.
 Center for Disease Control and Prevention. Prevalence of Childhood Obesity in the US. Retrieved May 3rd, 2016
from http://www.cdc.gov/obesity/data/childhood.html.
 Ross MM, Kolbash S, Cohen GM, Skelton JA. Multidisciplinary treatment of pediatric obesity: nutrition
evaluation and management. Nutr Clin Pract. 2010;25(4):327-34.