Module 3 Case Study Assignment NHM 365-901

Name: Stephanie Heinlein

Case 1: Pediatric Weight Management

JC is a 9-year-old girl accompanied by her mother and father. She was referred to the registered
dietitian by her pediatrician for a weight management consult.

DOB: 01/13/2006
Household members: father age 34, mother age 33, brother age 4
PMH: unremarkable
Surgical Hx: none
Family Hx: mother possible gestational diabetes; father HTN and hyperlipidemia

Biochemical data:
Lab Result Normal Range
Sodium (Na+) 142 mEq/L 136-145 mEq/L
Potassium (K+) 4.3 mEq/L 3.5 to 5.5 mEq/L
Chloride (Cl-) 101 mEq/L 95-105 mEq/L
Blood urea nitrogen (BUN) 8 mEq/L 7 to 20 mg/dL
Creatinine 0.9 mg/dL 0.6 to 1.2 mg/dL
Glucose 112 mg/dL 70-100 mg/dL
Calcium 9.2 mg/dL 9.0-11.0 mg/dL
Albumin 4.8 g/dL 3.5-5.0 g/dL
Prealbumin 33 mol/L 16-35 mol/L
Total cholesterol 165 mg/dL <170 mg/dL
HDL-C 34 mg/dL >55mg/dL (F); >45 mg/dL (M)
LDL-C 110 mg/dL <110 mg/dL
LDL/HDL ratio 3.23 <3.22 (F); <3.55 (M)
Triglycerides 114 < 150 mg/dL

Medications: Flintstones MVI

Allergies (medication and food): NKA
Previous nutrition therapy? No
Ht: 52.5 Wt: 96 lbs
Mothers stature = 66, Fathers stature = 70
24-hour recall: (Choose You Foods: Food Lists for Diabetes 2014)
Time Food and drink Kcals CHO (g) FAT (g) PRO (g)
Breakfast
2 frosted cherry Pop- 265 75g 20g 0g
Tarts (2 pastries)
8 oz whole milk (1 cup) 160 12g 8g 8g
16 oz orange juice (2 c) 240 60g 0g 0g
Lunch 2 bologna and cheese 270 0 30 0
sandwiches with 1 tbsp 200 0 16 14
mayonnaise each (6 f) 200 0 16 14
320 60 4 12
1-oz package Fritos corn 250 15g 11g 3g
chips (1 snack chips)
2 Twinkies (2 sweet 265 75g 20g 0g
rolls)
8 oz whole milk 160 12g 8g 8g
After- Peanut butter and jelly 120 30 0 0
school sandwich (2 slices 200 0 16 14
snack enriched bread with 2 160 30 2 6
tbsp crunchy peanut
butter 2HF and 2 tbsp
grape jelly- 2 CHO)
8 oz apple juice box (1c) 120 30 0 0
Dinner 6 fried chicken nuggets 70 15 5 7
1CHO+2MFP+1F 45 5
75
1 c mashed potatoes 160 30 2 6
(made with whole milk &
butter)
1 c fried okra 50 10 0 2
20 oz sweet tea (4CHO) 240 60 0 0
Snack 1 cup chocolate ice 320 30 20 0
cream
12 oz Sprite (2.5 CHO) 150 37.5 0 0
Total 4040kcal 581.5g 183g 94g

Additional assessment information:

JC reports a very good appetite with consumption of a wide variety of foods. She has been very
sedentary since her elementary school discontinued physical education several years ago. She
says her favorite activities are playing video games and watching television.
1. Using the Academy of Nutrition and Dietetics Evidence Analysis Library, summarize the
goals and guidelines for weight management in children ages 6-12 yo.

A registered dietitian nutritionist (RDN) should be a part of pediatric weight

management. An RDN should use intervention techniques to address diet, physical
activity, behavior, counseling, and family participation. Moreover, the RDN should try to
assess Resting Metabolic Rate (RMR), but estimating with Total Energy Expenditure is
an alternative. Obesity risks increase from a diet high in fat intake and caloric sugary
drinks, yet risks decrease from high vegetable and fruit consumption. Additionally, if the
RDN agrees a caloric restricted diet is suitable, research suggests an individualized
balanced macronutrient diet between 900 and 1,200 kilocalories may be beneficial in
weight management. The RDN should recommend family participation in nutritional
counseling and physical activity because these factors may be linked to obesity
prevention. Weight-loss surgery is generally not suitable for obese children. Counseling
should last for at least 3 months or until patient goals are achieved.

2. Calculate JCs BMI. (Show your work. Use the metric formula. Round to one decimal
place.) 96lb/2.2=43.63kg 52.5*2.54cm=133.35cm=1.33m

BMI = (43.63kg) / ((1.33m)^2) = 24.67

3. Complete the CDC growth chart for girls ages 2-20 with JCs information. What is JCs
BMI percentile? How would you classify her weight status based on BMI-for-age?

Based on the CDC growth chart, JC is over the 95th percentile, and would be
classified as obese.

4. Calculate JCs energy requirements (show your work).

(TEE should be calculated with PA estimated from your assessment above.)

Institute of Medicines EER for Overweight Girls Ages 3 Through 18 Years:

TEE = 389 (41.2 age [y]) + PA (15.0 weight [kg] + 701.6 height [m])
Where PA is the physical activity coefficient:
PA = 1.00 if PAL is estimated to be 1.0 < 1.4 (sedentary)
PA = 1.18 if PAL is estimated to be 1.4 < 1.6 (low active)
PA = 1.35 if PAL is estimated to be 1.6 < 1.9 (active)
PA = 1.60 if PAL is estimated to be 1.9 < 2.5 (very active)

TEE = 389 (41.2 10) + 1 (15.0 43.63 + 701.6 1.33)

 TEE = 1564.58 kcals

5. Evaluate JCs lab results. Identify any lab values that are out of normal range.

JCs lab results for fasting glucose, HDL-C, and LDL/HDL ratio are abnormal.
Moreover, JCs LDL-C results (110 mg/dL) are borderline high, as the normal
range is less than 110 mg/dL. JCs blood glucose test is used to test for diabetes
mellitus. Normal fasting blood glucose levels range for a pediatric population
between 70 and 100 mg/dL. JCs result of 112 mg/dL suggests impaired fasting
glucose or pre-diabetes.

6. Complete JCs diet record with kcals and grams of CHO, PRO, and FAT.
Total kcals: 4,040 kcals
CHO: 581.5g
FAT: 183g
PRO: 94g
CHO: 581.5g * 4 = 2326 kcals
FAT: 183g * 9 = 1647 kcals
PRO: 94 *4 = 376 kcals

7. Calculate her percentage of kcals from CHO, PRO, and FAT. (Show your work.)
CHO: 2326 kcals/4040 kcals = 57.6% of total kcals from CHO
FAT: 1647 kcals/4040 kcals = 40.7% of total kcals from FAT
PRO: 376 kcals/4040 kcals = 9.3% of total kcals from PRO

8. Select 2 appropriate nutrition problems, and write a PES statement for each.

1. Excessive energy intake related to consumption of high calorie foods as

evidenced by 24-hour recall.

2. Physical inactivity related to social support as evidenced by BMI and patients

report.

9. For each PES statement, establish an ideal goal of MNT, and briefly describe an
appropriate intervention to meet each goal.
Does each recommendation address the etiology (or at least the s/s) of your PES
statement?
1. Limit fat intake and substitute with reduced fat, or healthier fat options.
2. Participate in at least 30 minutes of physical activity, at least 5 days a week.

10. Monitoring and Evaluation:

When should the next counseling session with JC and her family be scheduled? Identify
at least 2 things you plan to assess during that follow-up visit?
 Does your plan for monitoring and evaluation relate back to s/s of PES statement?
Modifications in JCs diet can help her to manage her weight. Given her current
BMI and family history, I would recommend that JC begin to make lifestyle and diet
changes. I would like to see JC seven days after our initial consultation. I would like to
ask her how she feels after eliminating at least one daily snack and replacing it with a
whole fruit or vegetable. Does she still feel satisfied? Does she have any additional
cravings? Since our practice is patient-centered I would ask about the patients energy
level and follow up with her attitude towards these small yet beneficial diet and lifestyle
changes. Has she noticed any positive benefits from eating more fruits and vegetables the
past week? Also, was JC able to participate in 30 minutes of physical activity for at least
5 days? Research suggests family participation can help individuals succeed in
accomplishing exercising goals. I would suggest to JCs parents that together as a family,
they could have evening bike rides around their neighborhood. If it was difficult, I would
suggest JC use interactive video games to initially start getting more physical exercise. I
recommend using a Wii or Kinect gaming system. There are programs for fun activities
such as yoga and tennis on the Wii. She could start with light yoga classes in the morning
before school (on the Wii), and tennis in the evening. The Wii would be a great tool for
JC to begin moving more in a comfortable setting, such as her own home.

Follow ups are to be scheduled within twenty-eight days of the initial consult, unless
otherwise indicated. If JC cannot follow up in seven days, I would advise JC to visit my
office within twenty-eight days. I would follow up with JCs doctor to reassess her
glucose, HDL-C, LDL-C, and LDL/HDL ratio levels by our next visit. Additionally, I
would request another 24-hour recall to observe her diet. Did she notice that she became
more mindful during mealtimes? I would work diligently to recommend that my patient
found simple ways to eat healthy and enjoyable snacks, enjoy mealtimes, and
successfully manage her weight.

11. JCs parents ask about using over-the-counter diet aids, specifically Alli (orlistat). Based
on the EAL guidelines for pharmacological treatment of obesity in pediatric patients,
what would you tell them?

I would not recommend orlistat for JC at this time. Although orlistat is the only FDA
approved weight-loss medication for adolescents, it is recommends for ages 12 and
higher. Researchers have not studied this medication in children younger than 12 years.
Instead, we can work together to reduce caloric intake, and increase physical activity to
manage JCs weight for now.
Case 2: Bariatric Surgery

KC is an obese 36-year-old male admitted for Roux-en-Y gastric bypass surgery. He has tried to
lose weight by dieting several times, but each time he has ended up regaining more weight than
he lost. He has been obese since childhood, but he reports that he is currently at his highest
weight of 350 lbs.

DOB: 06/15/1976
Household members: lives alone
PMH: lifelong obesity, type 2 diabetes mellitus, HTN, osteoarthritis, hyperlipidemia,
obstructive sleep apnea
Surgical Hx: none
Family Hx: mother obesity, type 2 diabetes, CAD; father obesity, HTN, COPD
Medications prior to admission: Lasix 25mg/d, Lovastatin 30mg BID, Metformin 1000mg
BID
Ht: 71 (180.34cm) Wt: 350 lbs (159.10kg)
BMI: 49.1 kg/m^2

Biochemical data:
Lab Result Normal Range
Sodium (Na+) 138 mEq/L 136-145 mEq/L

Potassium (K+) 5.8 mEq/L 3.5 to 5.5 mEq/L

Chloride (Cl-) 99 mEq/L 95-105 mEq/L

Blood urea nitrogen (BUN) 15 mEq/L 7 to 20 mg/dL

Creatinine 0.9 mg/dL 0.6 to 1.2 mg/dL

Glucose 145 mg/dL 70-100 mg/dL

Albumin 4.2 g/dL 3.5-5.0 g/dL

Prealbumin 22 mol/L 16-35 mol/L

Total cholesterol 320 mg/dL <200 mg/dL

HDL-C 32 mg/dL >55mg/dL (F); >45 mg/dL (M)

LDL-C 232 mg/dL <110 mg/dL

LDL/HDL ratio 7.5 <3.22 (F); <3.55 (M)

Triglycerides 240 < 150 mg/dL

1. What are the criteria that would determine if an adult is a candidate for bariatric
surgery? What components of KCs medical history qualify him for surgery (be
specific)?

An adult is considered a candidate for bariatric surgery if their BMI is 40 kg/m2 or

greater, called class 3 obesity or morbid obesity. Another criteria for candidacy is a BMI
greater than 35 kg/m2 with Type 2 diabetes, CVD, Hypertension, Dyslipidemia, or sleep
apnea. Moreover, another factor is unsuccessful weight loss after diet and exercise.

KC would be a candidate because he is morbidly obese with a BMI of 49.1 kg/m2. Along
with poor weight management, KC has Type 2 diabetes, dyslipidemia, and Hypertension.
Additionally, he has not been successful with weight management after nutrition
intervention (dieting).

2. Briefly describe the following surgical procedures for weight loss. Which are
restrictive? Malabsorptive?
Adjustable gastric banding (aka AGB or Lap-Band)
Restrictive surgery. An adjustable silicone band is placed around the stomach,
near the entrance, to restrict and decrease food intake. This creates a pouch of
roughly 10 to 15 milliliters. As food enters and fills the small pouch, the patient
experiences a feeling of satiety. The silicone band can be adjusted by adding more
saline solution into the silicone band.
Vertical banded gastroplasty
Restrictive surgery. This is a popular surgery that reduces the size of the stomach
by creating a small gastric pouch, like adjustable gastric banding. In this
operation, stainless steel staples are applied in a vertical line to create a wall. A
mesh band is then used at the bottom of the gastric pouch to create a small
opening into the remaining stomach. Like adjustable gastric banding, this surgery
creates early satiety.
Roux-en-Y gastric bypass
Restrictive and malaborptive surgery. This is a gastric bypass surgery that entails
stapling to reduce the size of the stomach, then attaching the small intestine
(jejunum) at the newly created gastric pouch. The lower part of the stomach is
omitted.
Vertical sleeve gastrectomy
Restrictive surgery. In this surgery, the surgeon removes a large amount of the
stomach (gastrectomy) and creates a new stomach by stapling together the
 remaining portion of the stomach. This creates a much smaller stomach that
reduces the amount of food intake and quickly induces satiety.

3. One day post-op, KC begins sugar-free, clear liquids, broth, and sugar-free Jell-O.
Sugar-free liquids are prescribed to minimize the risk of Dumping Syndrome, a
common complication post-surgery. Define Dumping Syndrome.

Dumping syndrome, a common gastric bypass complication, is a gastric and circulatory

(vasomotor) response to great amounts of solid food and liquid entering the small
intestine in concentrated quantities. Common symptoms of dumping syndrome are:
nausea, bloating, early feelings of fullness, diarrhea, vomiting, abdominal pains,
sweating, and even tachycardia.

4. List 2 other complications associated with the Roux-en-Y procedure

Common complications associated with the Roux-en-Y procedure are tachycardia,
abdominal pains, internal hernias, and leaks. Other nutritional complications are
malabsorption of nutrients, and nutrient deficiencies.

5. Evaluate KCs pre-op labs. Identify any labs that are outside of normal range.
How might these change after weight loss?

KCs laboratory results show abnormal levels for glucose, potassium, total cholesterol,
HDL-C, LDL-C, LDL/HDL ratio, and triglycerides. Total cholesterol levels over 240
mg/dL are considered high risk. HDL-C levels below 40 mg/dL are considered low.
LDL-C levels greater or equal to 190 mg/dL are considered very high. Triglyceride levels
between 200 and 499 mg/dL are considered high. Finally, KCs fasting glucose levels are
quite high, and his potassium levels, possibly as a result of his diabetes, are high.

After weight loss and the surgery, KC would likely see reductions in his cholesterol,
glucose, potassium, and triglyceride levels.

6. Review his pre-op meds. Identify the aspect of KCs PMH that corresponds to each
medication. In other words, what was each medication prescribed to treat?

Metformin is used to treat diabetes mellitus by lowering blood sugar levels. Lasix
is a diuretic used to treat fluid retention and hypertension. Lovastatin is used to treat high
cholesterol by lowering LDL levels and raising HDL levels.

7. Use the Mifflin-St. Jeor equation to calculate KCs resting energy expenditure:
Males: REE (kcal/d) = (10*wt in kg) + (6.25*ht in cm) (5*age) + 5
 Weight=159.10kg height=180.34cm
REE=(10*159.10)+(6.25*180.34)-(5*39)+5
REE=2528.13 kcal/d

8. You are consulted to see this after his surgery for education about the full liquid diet
he will follow for the first three weeks post-op. Write a PES statement for this pt.
Food and nutrition-related knowledge deficit related to no prior education on full
liquid diet as evidenced by client report and status post gastric bypass surgery.
9. You see KC again when his diet is ready to be advanced from full liquids to puree
foods. List 4 appropriate foods that would provide a good source of protein.
While following the pureed diet, KC can consume food that has a consistency of
soft paste. KC can consume protein by eating yogurt, cottage cheese, hummus,
and pureed lean meats. During this stage, a patient may experience digestive
discomfort from eating spicy or dairy foods.
10. As KCs diet is advanced to soft foods and then DAT over the next 6 months, list 4
foods you would recommend avoiding or introducing very slowly. Provide a
rationale for each of your recommendations.
At this stage, KC can have more solid foods, yet in small quantities. Food should
be chopped into small pieces. Food quantities should not be larger than 1 cup, and
meat should be less than 2 ounces. I would advise KC to avoid fried foods
because of their high fat content. High fat foods may be hard for KCs digestive
system to process. Dried fruits, such as dried mangos, are another food to avoid
because they are difficult to chew and break down in digestion. Chunky peanut
butter is another food KC might want to avoid because it is sticky and difficult to
swallow. This food also contains nuts, which can be hard to chew well before
swallowing. KCs digestive system likely will not easily tolerate the nuts, or the
high fat of chunky peanut butter. KC might also avoid chewy and sticky candies,
such as caramels and taffy-like candies, because they are difficult to chew and
swallow. Additionally, it may be difficult for KCs digestion system to properly
breakdown foods high in added sugar, like candy. The simple sugars may also
cause dumping syndrome.