Case studys Flashcards
Why do the length/height percentiles change at 2 years of age and what is the important message to caregivers about this change?
Children <2 years are measured lying down (supine) on a length board and children > 2 years are measured standing with stadiometer
When a child is measured standing up, the spine is compressed/squashed a little, so their height is slightly less than their lying down length – the centile lines shift down slightly at age 2 to allow for this different type of measurement
What is the most important is to check whether the child continues to follow the same centile after this transition
No deviations greater than 1 intercentile spaces height and 2 centile lines for weight
What would you discuss regarding milestone achievements?
Window of achievement for each milestone is wide and there is great variability in young children.
state that there are time periods or windows of development that certain skills must be learned in order for subsequent learning to occur
Pull self to standing = by 12 months
e.g. Areta stood at 11 months = NORMAL
Walking alone = by 18 mo
e.g. Areta walked at 16 months = NORMAL
What factors do you need to consider when initiating a discussion about weight with a child and their parents?
- Asking for PERMISSION to talk about weight
- Be compassionate (sensitivity around the topic)
- Consider Cultural or socioeconomic factors
- Recognise your own bias around weight and not being judgmental
- Consider talking to the parents without the child to avoid negative impacts on self-esteem
- Avoid making assumptions about the family’s health behaviours
Calculate BMI and interpret BMI-for-age
- BMI = Weight / height^2
61 / 1.55^2
61 / 2.4025 = 25.3902 kg/m^2 - State the percentile e.g. “Above 97th percentile”
- category from BMI (under, normal, over, obese) e.g. “considered obese”
- Since 5 years old has been “consistently tracking” above the 97th percentile - taking into account of current status he has not grown into his body - maintained this HIGH BMI status for age.
How would you explain the childs BMI growth chart measure to their parents?
- weight is tracking above ideal and has been for some time (can visually show on graph where, relative to average - 50%)
- increased risk of poor health that could lead to low self esteem, depression, joint pain and other chronic health conditions later in life such as T2DM and CVD
What does the evidence say about screen time for children?
What is the recommendation for screen time for his age?
- There is a casual relationship between screen time and obesity in children and adolescents
-The main mechanisms are with increased eating while using screens, reduced energy expenditure, more food advertising exposure and affecting sleep patterns - Recommended screen time for children over 5 years of age is less than 2 hours a day (MOH. Eating for healthy children from 2-12 years)
Living in poverty means healthy food is less accessible, and it’s also difficult for children to participate in organised sport.
Make one physical activity suggestion and one diet/lifestyle suggestion without adding further financial stress.
PA:
- Encourage recreational time with siblings after school
- Walks for transport
Diet/lifestyle:
- Limit screen time to less than 2 hours per day
- Make a rule for no eating whilst gaming (e.g. set times for eating, snacks are to be eaten at the table)
- Purchase/prepare nutritious snacks to have in the cupboards rather than high calorific, nutrient poor xx = substitution rather than additional
List four complications of obesity
- Sleep apnoea
- Low self-esteem
- Orthotic/joint pain
- poor sleep
- Asthma
What are three factors that could be contributing to the food the child Timothy is eating?
- Poverty (difficult to purchase healthy food)
- Screen time (exposed to a lot of food advertising)
- Distractions while eating (Contributes to people eating more than they need)
- Cooking skills/knowledge (can not prepare healthy and nutritious meals for self)
Issues in female athletes diet
- Protein: impair growth and development
- Vegetarian: at risk of certain nutrient deficiencies (e.g., protein, calcium, vitamin D, zinc)
- Exercise means that her nutrient needs are high and her current diet might not support that.
- Potential learned behaviours around food from her mother which could lead to long term disordered eating.
- Skipping meals: missing out on key opportunities to meet energy needs
- Training could be affected by low energy intake which could increase her risk of injury in future.
What other questions might you ask to assess whether or not someone is at risk of Low Energy Availability (LEA)? If you think she is at risk what should you do? Your answer should also include a description of what LEA is
LEA: is when energy intake does not support expenditure (activity) meaning physiologic processes could be compromised.
- DO YOU HAVE YOUR PERIOD? and is it regular? (concerning if not have period before 16!)
- Injury history and recovery from injury
- Energy levels
- Does she have trouble concentrating at school
- Is her performance where she and her coaches expect it to me
- Weight history (although LEA can be present without weightloss)
*IF at risk, referred to a sports medicine team, or GP
Describe three factors that may have influenced bad eating patterns?
- Skipping meals
- Lack of knowledge around how much they need to eat to sustain their current activity levels
- Own restrictive eating patterns, avoiding dairy and meat
- Her mother restricting intake because of her perception that runners should be thin
Should age be used to determine energy and macronutrient requirements for adolescents? Why/why not?
NO, puberty (stage), sexual maturation and biological changes OCCUR at DIFFERENT ages for each individual. i.e. biological age
- Energy requirements are also influenced by activity levels, body size etc
e.g. small not active 16 year old, consume less than taller and active 15 year old.
What are two micronutrients a female is likely deficient in and why?
How could each of these affect her overall health?
Iron:
- Does not eat meat
- has a very restricted diet
:.
- Delayed or impaired growth, fatigue, increased susceptibility to infection
Calcium:
-Avoids dairy as it upsets her stomach but does not appear to have any milk alternatives in her diet
:.
- Delayed or impaired growth, reduction in functions such as blood clotting, heart and nerves, impact on bone health
Lifestyle aspects impacting bone health?
What would you recommend she do to mitigate this risk?
- No weight bearing exercise
In order to reach/maintain peak bone mineral density need to be jumping and muscle strengthening exercises.
:.
need to incorporate weight bearing exercise into training while not increasing her overall training load
*may reffer to exercise specialist - Little outdoor exposure (low Vit D)
:.
Encourage regular outdoor activity
The dad of a preschool-age child is worried that his daughter is not getting enough calcium. He would like to
know how low calcium intake could affect his daughter, current recommendations regarding calcium intake for
his daughter, and good sources of calcium. As the public health nutritionist what would you tell him?
Essential for: growth and maintenance of strong bones
Healthy nerve and muscle function
Blood clotting
RDI: 1,000mg/day
*ideally accumulate stores prior to adolescence and the denser the bones in childhood - the better prepared they will be to support the teenage growth spurt.
1.5-2 servings of milk or yoghurt
Concerning measurements
- HbA1c concentration (greater than 50 = diabetic and 41-90 = pre-diabetic)
- BMI <25 = overweight (risk factor for diabetes)
- high cholesterol (>8mmol/L = medication)
- Blood pressure > 120/80mmHg
what would you recommend to Jane to help her improve her physical activity?
- Prevention: Any movement is better than none.
- Weight loss: 60 mins per day
- Encourage to get up regularly - breaking up prolonged periods of sitting which is better for regulating blood glucose levels.
As muscle contaction enhances glucose uptake in the absense of insulin release.
E.g. fill up water bottle and walk to toilet more often - Prescribe to an exercise specialist for further assistance and exercise prescrition to aid her weight managemet/loss.
List the dietary components of lifestyle interventions aimed at reducing the risk of diabetes.
- Consuming fibre (25g/day) (quality of cho)
- Lower saturated fat
- Reduce total energy intake
- PA guidelines
Do you think Jane should be worried about her bone health?
What strategies could she consider to increase her calcium intake?
If limits dairy intake she may be susceptible to calcium deficency. Alternative milks such as
Calcium content of plant based milk?
Barista plant based milk are fortified with lower calcium content than non barista versions.
Therefore make it at home or ensure the brand using at café contains an adequate amount of calcium i.e. 100-130mg/100ml
Calculate BMI and classify her weight status. What other measures/biomarkers are of concern? Explain.
84 / (1.63 x 1.63) = 31.6158
BMI = 31.6kg/m2 which is obese class 1
HbA1c = Pre diabetes (45mmol/mol
Family history of heart attack below 50 years
Lipid profile: above all cuts offs
Other measures of concern include (one mark for each – explain why it is of concern):
* HbA1c (pre-diabetes)
* Lipids (high)
* Blood pressure (high)
* Waist circumference (high risk)
* History of smoking
* Family history of heart attack
At what age should a 55 year old female first cardiovascular disease risk assessment taken place?
55 - 10 = 40 years old and follow up every 2 years as risk is 10%
(family history of heart attack before 50y)
Is a HbA1c concentration greater than 40mmol/L problematic?
Yes, her HbA1c indicates she has pre-diabetes (1 mark)
There is an increased risk of complications associated with hyperglycemia and increased risk of CVD (these include blindness, kidney disease, risk of lower limb amputation/ulcers) (1 mark)
Identify components of their diet that may be contributing to their risk of disease.
Suggest a food based modification that could help to reduce risk for each of the components you identify. (8 marks)
High saturated fat intake (full fat diary, processed meat)
→ swap to low fat diary, use lean cuts of meat, plant based margarine, swap ice-cream for low fat yoghurt
Low fibre/wholegrain intake (this could also be reduce intake of refined CHO)
→ replace white bread for higher fibre (lower sodium) alternatives, or whole grain cereal/porridge, replace snax crackers with wholegrain crackers, or fruit and nuts, add chickpeas, legumes etc to lunch or dinner.
No fruit
→ replace morning tea/afternoon tea and other snacks with fruit, add fruit to breakfast, add fruit for pudding.
Low vegetable intake
→ vegetable soup at lunch (with beans/legumes even better!), salads at lunch, more servings of non-starchy vegetables at dinner.
High intake of energy dense foods (reduce energy intake)
→ replace snack foods with fruit/vegetable/wholegrain/low fat yogurt options, reduce sugar in tea.
Alcohol intake
→ reduce/limit alcohol
What age-related physiological changes are you likely to see in Cyril in relation to his nervous system. What impact might this have on his nutrition status?
- Blunted appetite regulation (1mark)
- Blunted thirst regulation (1 mark)
- Declining number of olfactory receptors, blood flow to nasal smell organ and increased thickness of nasal mucus
- Reduced nerve conduction velocity, affecting sense of smell, taste, touch cognition
- Changed sleep as the wake cycle becomes shorter
At least 1 mark for explaining an impact on his nutrition status:
- Further decline due to unintentional weight loss. (1 mark)
- Dehydration likely due to a decline in appetite and blunted thirst/dislike of water. (1 mark)
- If this was to continue his malnutrition status would persist. (1 mark)
What is MNA. What does a screening score of between 0 and 7 mean?
- MNA = Mini Nutritional Assessment and it uses six screening questions to identify an individual’s risk of malnutrition. (1 mark)
- A score between 0-7 indicates malnutrition. (1 mark)
What is the recommended dietary intake of protein for older adults like Cyril?
1-1.5g/ kg of body weight. Or 81g per day for older adults (>70y (1.07g/kg)) when weight is not known.
Protein requirement for men >70 years: 81 g/day or 1.07 g/kg/day (1 mark)
Cyril appears to be lacking sufficient protein in his diet. Provide two dietary suggestions to help improve his overall protein intake.
- Ensure he has a small amount of protein at all main meals to improve protein synthesis and utilisation (1 mark)
- Try adding egg as a base for breakfast (e.g., omelette, scrambled) (1 mark)
- Add milk powder to cereal at breakfast (1 mark)
- Add meat such as mince or legumes to his evening soup (1 mark)
Provide four practical suggestions to help Cyril improve his overall energy intake?
1 mark for each point, maximum 4 marks (use HEHP resources for ideas).
○ Small meals and snacks can be more appetizing than large portions (1 mark)
○ Include high energy snacks (such as yoghurt, small sandwich, muffin) in his diet (1 mark)
○ Try adding milk powder/protein powder to boost protein without adding volume (1 mark)
○ Enjoy a pudding as often as he can (1 mark)
○ Use blue top milk (1 mark)
○ Replace tea and coffee with a milky drink (1 mark)
Describe the age-related changes that could put Cyril at risk of vitamin B12 deficiency.
Changes in GI system:
- Decreased saliva secretion
- Difficulty swallowing (dysphagia)
- Decreased secretion of hydrochloric acid and digestive enzymes
- Decreased vitB12 absorption (due to decreased acidity, as acidic environment is required for absorption)
- Decreased peristalsis :. Less employing
- Atrophic gastritis – atrophy of stomach mucosa resulting in reduced gastric acid, intrinsic factor and pepsin, vitamin B12 needs to bind with intrinsic factor (IF) for absorption in the small intestine, this poor absorption overtime can result in vitamin B12 deficiency (2 marks)
- Other gastrointestinal disorders can affect vitamin B12 absorption, particularly the high prevalence of H. pylori infection which decreases hydrochloric acid and therefore reduces vitamin B12 absorption (2 marks)
Or 0.5 mark each for stating:
- Medications – common for older people to take medication that suppresses stomach acid secretion
- Reduced food intake – common for poor appetite in older adults which may lead to lower vitamin B12 intakes
