This document summarizes a case study of an 11-year-old girl seeking treatment for childhood obesity. It provides background on childhood obesity rates and risk factors. An initial assessment found the girl to be in the 99th percentile for BMI and at risk for comorbidities. After two follow-up appointments spanning 4 months, she lost 12 pounds through dietary changes like reducing juice and snacking, and increased physical activity goals. Her nutrition diagnosis addressed high sugar intake and sedentary lifestyle contributing to obesity.

1. Management of Childhood
Obesity through Nutrition
Intervention
CNMC: Outpatient Case Study
Margery Swan, Dietetic Intern
University of Maryland, College Park

2. Presentation Outline
• Brief overview of childhood obesity
o Prevalence
o Suspected etiologies
o Potential comorbidities
o Treatment Options
• Case Study: 11 YOF (L.E.)
o Initial Assessment: 1/11/13
o First Follow Up: 4/9/13
o Second Follow Up: 5/14/13

3. Childhood Obesity
• In District of Columbia: 35% children overweight /obese1
o National average: ~ 33%2
• More than doubled in past 30 years
• More likely to be obese as adults3

4. Possible Etiologies
• No safe/appealing
area in communities to
be active
• Limited access to
healthy, affordable
foods
o In DC – Ward with lowest
healthy food options = highest
obesity rate4
• Greater availability of
high energy-dense
foods and sugary
beverages
• Sugary drinks and less
healthy foods on
campuses
• Lack of daily, quality PE
in majority of schools
• Television and media
• Increasing portion sizes
• Lack of breastfeeding
support

5. Potential Comorbidities
• Obesity increases risk of . . .
o Endocrine: Type II Diabetes
• 50% obese men and 70% obese women5
• Acanthosis nigricans seen in children (sign of insulin
resistance)
o Circulatory: Cardiovascular Disease
• 70% obese children have at least one risk factor
o GI:
• Non-alcoholic Fatty Liver Disease, GERD and Gallstones
o Respiratory: Asthma and Sleep Apnea
o Skeletal: Joint Problems/Arthritis
o Reproductive: Polycystic ovary syndrome

6. Treatment Options
• Nutrition education and counseling
o <13 YO parental involvement recommended
o Focus on diet and physical activity
• Creating small, specific and realistic goals
• Multi-disciplinary Approach
o Physician/Nurse Practitioner, RD, Behavioral Counselor, and
Exercise Specialist6

7. Surgical Intervention
• Sleeve Gastrectomy
o CNMC Study7:
• Average weight lost: > 65lbs or 40%
loss of excess body weight within 1
year
• Fewer Complications than Gastric
Bypass
o ***Some insurances will not cover

8. Case Study

9. Background:
• 11YOF Arab-American
o Initially seen in January for weight management (wt: 90.3kg)
o Prior to RD appointment initiated some lifestyle modifications
o Set the following goals:
• Use checklists to keep track of activity goals
• Think about healthy plate for meals and snacks
• Aim for ≥ 20 minutes physical activity
o Follow Up set for 2 months at IDEAL Spring Valley

10. Follow Up #1: April 2013
• IDEAL Clinic – Obesity Evaluation
• Additional Background Information:
o Weight History: Accelerated weight gain for past 5 years
o Activity Screen: 4 hours weekdays
o Physical Activity: PE class, Playing w/friends, summer camp scheduled
o Family History:
• Paternal: Father deceased d/t massive stroke, s/p 2 MIs, history of
obesity
• Maternal: Mother has hypertension, Aunt with Type II DM
o Physician Assessment:
• Dysmetabolic Syndrome
• Acanthosis Nigricans
• Abnormal Weight Gain
• Dysthymic Disorder
• Morbid Obesity

11. Follow Up #2: May 2013

12. Nutrition Assessment
• Anthropometrics:
o Weight: 84.8kg, Height: 157cm (~95th %ile), BMI: 34.4 (BMI %ile: 99.4%)
• Biochemical:
o 8/24/12:
LE’s Lab Results
Total Cholesterol 129
TG 138
HDL-C 40
LDL-C 61
FBG 83
TSH 0.899
AST/ALT 15/18

13. Diet/Activity Recall
• Typical Meal-time Schedule
o Breakfast, lunch, large snack in afternoon and small dinner
• 24 Hour Recall:
o Breakfast: 1C 2% milk, 1 slice of bread + 1/3 less fat cream-cheese
o Lunch(12:30pm): Packed vegetables and chicken meat-balls
o Snack(4pm): salad, fruit and almonds
o Dinner(6pm): fruits or cabbage soup
• Activity
o Riding bike and racing friends

14. Estimated Needs
• Kcals:
o DRI for Girls 9-11 YO: 42kcals/kg/day
o Using IBW total kcals = 2,184kcals/day, however DRIs
kcals/day = 1,550kcals
• Protein:
o DRI for Girls 9-11 YO: 0.95g/kg/day
o Using IBW total grams protein/day = 49.4grams
• Fluid:
o Using Holliday Segar Method and Actual Weight: = 2,796mL
o IBW: 52kg, % IBW: 163%

15. Weight Loss Progress
Weight Height BMI %ile BMI for Age
January, 2013 90.3kg 156.2cm 37 > 99.5%ile
April, 2013 87.3kg (↓ 6.6#) 156.2cm 35.78 99.5%ile
May, 2013 84.8kg (↓ 5.5#) 157cm 34.4 99.4%ile
Total Weight
Lost To-Date:
12lbs in 4 months

16. 11

17. Nutrition Diagnosis
Obesity related to high intake of sugary
beverages and sedentary lifestyle as
evidenced by > 99th percentile BMI for age
and initial diet/activity recall.

18. Goal-Setting
- Dietary Goals:
1. Switch to 1% or skim milk
2. Incorporate protein after school
3. Limit juices to ~6 - 8oz/day
- Activity Goals:
1. Look into summer camps and programs
2. Move at least 60min/day, 7 days/week
3. Implement reward system using behavior rather than
basing rewards on number of pounds lost
- Child Confidence Scale: 10

19. References
1 Quality, National Initiative for Children's Healthcare. "Washington DC State Fact
Sheet ." 2008.
2 Centers for Disease Control and Prevention . Childhood Obesity Facts. Atlanta, 13
February 2013.
3 Biro, Frank and Michelle Wien. "Childhood Obesity and Adult Morbidities ." American
Journal of Clinical Nutrition (2010): 14995-15055.
4 Department, Government of DC: Health. Obesity in the District of Columbia . Washington,
DC: Government of the District of Columbia , 2010.
5 American Heart Association . Understand Your Risk for Diabetes. 5 July 2012. 22 May 2013.
6 Barlow, Sarah and Expert Committee. "and Treatment of Child and Adolescent
Overweight and Obesity: Summary Report ." 2007. Pediatrics.
7 Children's National Medical Center. Early Study Shows Sleeve Gastrectomy is Safe
Alternative to Gastric Bypass for Adolescents with Morbid Obesity . Washington, 3 August
2012.