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Patient

History: Miss R is an 11 year old Hispanic female referred to you by her PCP for a
consult on treatment fore obesity & fatty liver. Miss R. is accompanied by her mother
who does most of the talking as the patient is embarrassed and withdrawn. Patient is an
only child who enjoys watching movies and reading books. Patient has recently
complained of being tired, falling asleep at school, and mild abdominal pain. She was born
LGA at 10 lbs 2 oz. Mother states she has always been a big girl.
PMH: LGA, Childhood Obesity
Meds: none
Family hx: mother and father are overweight and have Type 2 Diabetes

Physical History:
General Exam: obese female
Vitals: Temp 98.6 F, BP 138/89 mm Hg, HR 84 BPM, RR 23
Ht: 57 (25th %tile) Wt: 152lb (>95th %tile) BMI 32.9 (>95th %tile)
CT scan (recent) shows the presence of a hepatic steatosis

Nutrition History:
General: Reports adequate appetite. Miss R. will eat some vegetables and fruit but prefers
starchy and high fat foods. She sneaks candy from her cousins after school. Mom cooks
traditional Hispanic meals at home, but a couple times per week they will go to fast food
and get a burger or pizza.
Usual Dietary Intake:
Breakfast: 2 breakfast burritos with cheese, eggs, sausage, beans, and homemade
tortillas (made with lard), and a large glass of juice
Snack: granola bar
Lunch: school lunch (pizza or burger, with fries, maybe a fruit, chocolate milk or juice,
with a cookie
Snack: she is offered fruit but prefers candy and dried cereal (Fruit Loops) with
regular soda
Dinner: 3-4 tortillas (made with lard), cheese, beef or chicken, maybe a vegetable
(corn or peas), and a glass of whole milk
Snack: microwavable popcorn with butter or ice cream
Food allergy/intolerance: NKFA
1. In the table of laboratory values below, place an X or a checkmark in the appropriate
Interpretation column l to indicate whether the values are high (), low () or
within normal limits (WNL). (2 points) 0.25 each item


Fasting Labs 1/20/2017 Patient: Miss R.
Lab Value Interpretation
WNL HIGH LOW
ALT 80 U/L X
AST 28 U/L X
Glucose 117 X
mg/dL
Hemoglobin 6.9% X
A1c
Total 245 X
Cholesterol mg/dL
LDL 163 X
Cholesterol mg/dL
HDL 22 X
Cholesterol mg/dL
Triglycerides 198 X
mg/dL


2. Briefly explain how Insulin Resistance can promote Non-Alcoholic Fatty Liver
Disease (NAFLD). (2 points)

Insulin resistance can promote NAFLD by inhibiting glucose-mediated transport in
the muscles and lipogenesis in adipose tissue and by promoting de novo lipogenesis
in the liver and lipolysis in adipose tissue. The glucose from dietary CHO is
converted to FFA and then to TGs in the liver. The TGs from adipose tissue are
converted to FFA, travel to the liver, and converted back to TGs. The liver then has
an excess of TGs and can only export so much of it as VLDL.


3. List which type of nutrient and specific foods in Miss Rs diet that are contributing
the most to each of the parameters below: (3 points)

a. Triglyceride level:
i. Nutrient: CHO, fat
ii. Foods: Candy, cookie, cereal, ice cream, granola bar, chocolate milk,
milk, juice, soda, pizza, burgers, tortillas, fruit, corn, popcorn, cheese,
sausage, fries, beef, pizza/burger, eggs, and possibly other oils used to
cook food


b. Total Cholesterol and LDL-cholesterol level:
i. Nutrient: CHO, Fat
ii. Foods: Candy, cookie, cereal, ice cream, granola bar, chocolate milk,
milk, juice, soda, pizza, burgers, tortillas, fruit, corn, popcorn, cheese,
sausage, fries, beef, pizza/burger, eggs, and possibly other oils used to
cook food


c. Fasting blood glucose level:
i. Nutrient: CHO
ii. Foods: Candy, cookie, cereal, ice cream, granola bar, chocolate milk,
juice, soda, pizza, burgers, tortillas, fruit, corn, popcorn, fries, milk

4. Would you recommend that Miss R cut out the 5-6 tortillas she eats each day? Why
or why not? You must justify your answer & provide a dietary suggestion. (2 points)

I would recommend Miss R to substitute her flour tortillas for corn tortillas, if
possible, and reduce her consumption to 1 to 2 6-inch tortillas per day. Corn tortillas
are typically not made with lard and are a whole grain, which is a win-win, but a
flour tortilla made with vegetable oil would also be a good substitution. The lard is
most likely a contributor to her negative blood values (high LDL, high total chol, and
low LDL) and the high consumption of tortillas would have an impact on her weight,
fatty liver, and glucose levels. I want to be sensitive to cultural traditions, not only to
be understanding but also Miss R will be more likely to stick to a reduction rather
than a complete exclusion.


Use the following supplemental reading to answer the next 2 questions: 2013 Position
Paper of the Academy of Nutrition & Dietetics: Intervention for Prevention and
Treatment of Pediatric Overweight and Obesity

5. This case study represents an example of clinical secondary prevention and
management of pediatric weight and obesity. Select which stage of intervention you
feel will be most appropriate for this situation: (1 point)

______ Stage 1: PCP intervention

______ Stage 2: PCP & RD or other professional lifestyle behavior modification

___X___ Stage 3: Multi-component family-based intervention



6. What type of dietary intervention plan has typically resulted in the best outcomes
and sustainability for adherence: (1 point)

_____ Structured meal plan

__X___ Non-diet plan (Better food choices approach)



7. Write an appropriate MNT goal statement for this case: (2 points)

Weight loss of 5% of CBW (about 8#) over the next 3 months.



8. List 4 Dietary Recommendations that you would include in your Intervention Plan &
which would relate to your MNT goal: (4 points)

a. Reduce servings of tortillas from 5-6 to 1-2 per day.

b. Include one whole grain two meals a day for the next 3 months.

c. Include one serving of vegetables two meals a day for the next 3 months.

d. Diversify diet by trying one new vegetable or one new whole grain once a
week for the next 3 months.

9. List 3 items that you would Monitor and Evaluate at a 3 month follow-up: (3 points)

a. Weight

b. 24-hour recall

c. Blood lab: blood glucose, LDL/chol/HDL/TG