Cherise is an18-year-old girl and high school senior who saw a nurse at the school-based clinic. While taking her medical history, the school nurse noted that Cherise had frequent headaches and fatigue. Cherise’s blood pressure reading fell into the 92nd percentile. The school nurse referred her to a local community clinic for a more thorough evaluation. A physician’s assistant (PA) at the community clinic took a social history and performed a physical examination on Cherise. An SMR stage of 5 was noted. The PA noted that Cherise’s BMI was at the 94th percentile for her age and gender. Her blood pressure registered at the 94th percentile. The family history revealed a strong family history of cardiovascular disease, diabetes and renal disease. Cherise thought her father may be taking medication for his cholesterol and blood pressure, but reported no health issues for her mother. No signs of acanthosis nigricans were noted on the physical examination. Laboratory results show that Cherise had elevated total, non-HDL, and LDL cholesterol levels along with a marginally low HDL level. The liver enzyme and blood glucose values were at the upper end of normal. A referral was made for Cherise to see a registered dietitian/nutritionist for diet and exercise counseling. The outpatient dietitian/nutritionist (RDN) reviewed Cherise’s medical history, confirmed her family history of cardiovascular disease, and measured her height and weight. Cherise’s BMI value plotted at the 94th percentile. The RDN completed a 24-hour dietary recall with Cherise, beginning with the last thing she had eaten that day and working backward to facilitate a complete and accurate recall. The RDN also inquired about usual dietary patterns and physical activity as well as the presence of any food allergies/intolerances and avoidances. Cherise reported that she usually skipped breakfast because she didn’t have time to eat in the morning, but she often buys a caramel macchiato from the school store at 7:15 am. The first food Cherise ate most days was usually a snack from the vending machine at 10:30 am, which consisted of a granola bar or a bag of chips and a juice drink. Occasionally she would purchase a la carte lunches of tacos or a burger, but generally she skipped lunch. Cherise was out of school at 2 pm each day, at which time she went to work as a clothing sales clerk at the local mall. She had a half-hour break in the late afternoon or early evening, when she would go to the food court for dinner. Her evening meal usually consisted of one to two slices of pepperoni pizza, two tacos, or one to two pieces of fried chicken with a soft drink. About half of the time she also ordered fries or nachos. When Cherise returned home from work at 10:15 pm, she usually had a snack of ice cream, tortilla chips, spicy cheese puffs, or microwave popcorn while doing her homework. A large glass of juice or lemonade usually accompanied her snack. On weekends, Cherise worked as many hours at the mall as she could, often meeting friends for pizza or fast food on her nights off. Her physical activity consisted of walking between the house and bus stop in the morning and evening, walking around school between classes and being on her feet in the evenings at her sales job.
The RDN counseled Cherise regarding a healthy diet and physical activity. A follow-up visit was scheduled 4 weeks in the future. Cherise did not return to see the RDN for her follow-up appointment and did not keep her follow-up appointments with the PA. Five months later, she returned to see the PA at which time her health status was reassessed. Cherise’s blood pressure was still at the 94th percentile and her BMI now at the 95th percentile,. When questioned about her dietary habits and physical activity, Cherise reported that she had tried to follow the recommendations of the RDN but found it hard because of time constraints. She reported that she wanted to lose weight and thought she could do this because she would graduate in a few weeks and would have more time to devote to exercise and cooking. The PA suggested she see the RDN again for more dietary and physical activity counseling. The RDN reviewed the previous dietary recommendations with Cherise and suggested she attend the clinic’s 12-week weight management program. Cherise attended the first five sessions of the program, then stopped. She had lost 12 pounds during the five sessions. Several months later Cherise was once again seen by the PA. Her blood pressure continued to be elevated and her BMI was plotted at the 94th percentile. When questioned about the weight loss program, Cherise reported that her mother had changed jobs and lost her health insurance benefits, so she could no longer participate in the program. The RDN connected Cherise with the local YMCA, which offered a weight management program for adults on a sliding fee scale. Five months later Cherise’s BMI was assessed at 26.8 and a weight loss of 19 pounds from previous levels was noted.
Nutrition Diagnostic Statements
1. Excessive energy intake as evidenced by dietary history and BMI at 94th %tile. (NI-1.3)
2. Excessive fat intake as evidenced from dietary history. (NI – 5.6.2)
3. Obesity as evidenced by BMI of 94th %tile. (NC 3.3.1)
4. Limited adherence to nutrition-related recommendations as evidenced by BMI up 1%tile at followup visit. (NB-1.6)
Nutrition Care Questions
1. How would you classify Cherise’s blood pressure based on the reading at the school nurses office?
2. How would you classify Cherise’s weight based on the readings at the first visit at the community clinic? Based on this classification, what laboratory tests would you order to be consistent with the NHLBI recommendations?
3. What type of diet should the RDN recommend Cherise follow, based on her blood pressure, weight and laboratory results?
4. What specific strategies would be beneficial for the RDN to recommend to Cherise regarding improving her dietary intake?
5. What strategies would you recommend for Cherise to change her level of physical activity?
6. Based on the staged treatment recommendations for weight, what type of program would the RDN recommend for Cherise?