Pediatric Outpatient Case Study

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.