Management of childhood obesity through nutrition intervention

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Pediatric Outpatient Case Study

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  • http://www.cdc.gov/obesity/childhood/problem.htmlThe wards with the most grocery stores, organic food and farmers markets, Wards 2 and 3, had the lowest rates of obesity; Ward 8 had the fewest healthy food options and had the highest rate of obesity.
  • - Cut out juice, switch to 1% milk
  • 10-19 years old, levels under 90 mg/dL are acceptable. HDL cholesterol in children is considered acceptable if it is over 45
  • DRI – average daily nutrient intake of individuals over time
  • Weight Loss Goal: 1-2#/week according to Obesity Expert Panel
  • Obesity >95th %ile BMI for age
  • Management of childhood obesity through nutrition intervention

    1. 1. Management of ChildhoodObesity through NutritionInterventionCNMC: Outpatient Case StudyMargery Swan, Dietetic InternUniversity of Maryland, College Park
    2. 2. Presentation Outline• Brief overview of childhood obesityo Prevalenceo Suspected etiologieso Potential comorbiditieso Treatment Options• Case Study: 11 YOF (L.E.)o Initial Assessment: 1/11/13o First Follow Up: 4/9/13o Second Follow Up: 5/14/13
    3. 3. Childhood Obesity• In District of Columbia: 35% children overweight /obese1o National average: ~ 33%2• More than doubled in past 30 years• More likely to be obese as adults3
    4. 4. Possible Etiologies• No safe/appealingarea in communities tobe active• Limited access tohealthy, affordablefoodso In DC – Ward with lowesthealthy food options = highestobesity rate4• Greater availability ofhigh energy-densefoods and sugarybeverages• Sugary drinks and lesshealthy foods oncampuses• Lack of daily, quality PEin majority of schools• Television and media• Increasing portion sizes• Lack of breastfeedingsupport
    5. 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 insulinresistance)o Circulatory: Cardiovascular Disease• 70% obese children have at least one risk factoro GI:• Non-alcoholic Fatty Liver Disease, GERD and Gallstoneso Respiratory: Asthma and Sleep Apneao Skeletal: Joint Problems/Arthritiso Reproductive: Polycystic ovary syndrome
    6. 6. Treatment Options• Nutrition education and counselingo <13 YO parental involvement recommendedo Focus on diet and physical activity• Creating small, specific and realistic goals• Multi-disciplinary Approacho Physician/Nurse Practitioner, RD, Behavioral Counselor, andExercise Specialist6
    7. 7. Surgical Intervention• Sleeve Gastrectomyo CNMC Study7:• Average weight lost: > 65lbs or 40%loss of excess body weight within 1year• Fewer Complications than GastricBypasso ***Some insurances will not cover
    8. 8. Case Study
    9. 9. Background:• 11YOF Arab-Americano Initially seen in January for weight management (wt: 90.3kg)o Prior to RD appointment initiated some lifestyle modificationso 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 activityo Follow Up set for 2 months at IDEAL Spring Valley
    10. 10. Follow Up #1: April 2013• IDEAL Clinic – Obesity Evaluation• Additional Background Information:o Weight History: Accelerated weight gain for past 5 yearso Activity Screen: 4 hours weekdayso Physical Activity: PE class, Playing w/friends, summer camp scheduledo Family History:• Paternal: Father deceased d/t massive stroke, s/p 2 MIs, history ofobesity• Maternal: Mother has hypertension, Aunt with Type II DMo Physician Assessment:• Dysmetabolic Syndrome• Acanthosis Nigricans• Abnormal Weight Gain• Dysthymic Disorder• Morbid Obesity
    11. 11. Follow Up #2: May 2013
    12. 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 ResultsTotal Cholesterol 129TG 138HDL-C 40LDL-C 61FBG 83TSH 0.899AST/ALT 15/18
    13. 13. Diet/Activity Recall• Typical Meal-time Scheduleo 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-cheeseo Lunch(12:30pm): Packed vegetables and chicken meat-ballso Snack(4pm): salad, fruit and almondso Dinner(6pm): fruits or cabbage soup• Activityo Riding bike and racing friends
    14. 14. Estimated Needs• Kcals:o DRI for Girls 9-11 YO: 42kcals/kg/dayo Using IBW total kcals = 2,184kcals/day, however DRIskcals/day = 1,550kcals• Protein:o DRI for Girls 9-11 YO: 0.95g/kg/dayo Using IBW total grams protein/day = 49.4grams• Fluid:o Using Holliday Segar Method and Actual Weight: = 2,796mLo IBW: 52kg, % IBW: 163%
    15. 15. Weight Loss ProgressWeight Height BMI %ile BMI for AgeJanuary, 2013 90.3kg 156.2cm 37 > 99.5%ileApril, 2013 87.3kg (↓ 6.6#) 156.2cm 35.78 99.5%ileMay, 2013 84.8kg (↓ 5.5#) 157cm 34.4 99.4%ileTotal WeightLost To-Date:12lbs in 4 months
    16. 16. 11
    17. 17. Nutrition DiagnosisObesity related to high intake of sugarybeverages and sedentary lifestyle asevidenced by > 99th percentile BMI for ageand initial diet/activity recall.
    18. 18. Goal-Setting- Dietary Goals:1. Switch to 1% or skim milk2. Incorporate protein after school3. Limit juices to ~6 - 8oz/day- Activity Goals:1. Look into summer camps and programs2. Move at least 60min/day, 7 days/week3. Implement reward system using behavior rather thanbasing rewards on number of pounds lost- Child Confidence Scale: 10
    19. 19. References1 Quality, National Initiative for Childrens Healthcare. "Washington DC State FactSheet ." 2008.2 Centers for Disease Control and Prevention . Childhood Obesity Facts. Atlanta, 13February 2013.3 Biro, Frank and Michelle Wien. "Childhood Obesity and Adult Morbidities ." AmericanJournal 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 AdolescentOverweight and Obesity: Summary Report ." 2007. Pediatrics.7 Childrens National Medical Center. Early Study Shows Sleeve Gastrectomy is SafeAlternative to Gastric Bypass for Adolescents with Morbid Obesity . Washington, 3 August2012.

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