Nutrition Assessment History
Alicia, a 14-year-old girl with Down’s syndrome, is admitted to a mental health services facility for treatment of sleep apnea, prediabetes, and severe behavioral activities. The contributing factor to the medical problems is her severe obesity. Before her admission to the facility she had been in public school in a special education program, but her behavior was so difficult to control that the school transferred her to this mental health facility. She is the only individual in her family with Down’s syndrome, and was born when her mother was 40. There is a history of diabetes in the family and food has always been used as a reward for Alicia.
Food/Nutrition-Related History Alicia’s birthweight was 7 lb 8 oz, her birth length was 19,” and she was full term. She was breast fed until age 3 months when she was transferred to Similac formula and reportedly had no feeding problems other than consuming more than 36 oz of milk daily, and eating baby food in unusually large amounts. Her weaning to a cup was late, at 18 months, and her motor-skill development was late; she did not walk until 28 months of age. She also had low muscle tone. By the time she was 12 months of age her weight was 28 lb, placing her above the 95th percentile. Each subsequent year she remained between the 75th and 95th percentile for her weight but at the 10th percentile for her height. During her preschool and school years Alicia’s intake was reported as very limited in variety with a heavy concentration of foods from fast food restaurants, and little intake of fruits and vegetables. She drank milk, but preferred soft drinks and sweetened tea. She also consumed many sweetened desserts, cookies, and bakery products. Although her mother reported trying to control Alicia’s overeating behavior, a grandparent was very indulgent. Alicia also developed behavioral problems with a great deal of acting out at home and at school. It was this behavior that led to her referral to the mental health facility
Anthropometric measurements:
Weight 247 # . 97th% Height: 560- 50% to 75% H/W relationship: . 97th% BM index: . 97% Estimated energy needs: 1716 kcal Estimated energy intake at home: 3000 kcal (based on maternal report) Estimated protein need: 52 g
Biochemical Data
Hgb: 14 gm/dL —(12-14.9) Hct: 36% (39.) low Cholesterol: 210 mg/dL (high) ,170 acceptable Glucose: 120 mg/dL (high) 70-100 acceptable Medications: Topomax and Clonidine, for seizures and behavioral problems. Diet order after physical examination: 1500 calories per day and exercise.
Nutrition-Focused Physical Findings
Excessive appetite Dry skin Inactivity with behavioral outbursts related to walking Feeding problems—very rapid eating with possibility of choking Low muscle tone Constipation
Nutrition Diagnostic Statements
Obesity: NC 3.3 Excessive intake of carbohydrates: N1-53.2 Excessive oral food/beverage intake: NI-2.2
Intervention Goals
1. Weight loss and acceptance of difference in food provided.
2. Increase consumption of high fiber foods.
3. Limit between meal to fruit and vegetables. ND-1
4. Counsel parents related to meal management and poor behavior related to food. FH 3.1
5. Increase physical activity at school and home. FH 6.3
Nutrition Intervention
1. Modify the menus to provide 1500 calories including snacks. ND-1
2. Provide copies of menu to group home staff and parents. ND 1.2
3. Increase availability of fresh fruit and raw vegetables for snacks. ND 1.2
4. Increase water intake. ND 1.3
Monitoring and Evaluation
1. Weigh monthly and plot on growth grid with report to parents.
2. Counsel parents monthly or as necessary related to food intake and exercise at home.
3. Record amount of walking at school with teachers and other students.
Nutrition Care Questions
1. Teachers report that student eats only part of the meal provided and refuses the snacks offered. What would be your response?
2. The parents report in their monthly conference that Alicia is very rebellious and refuses to participate in the family activities unless provided with a trip to a fast food restaurant for hamburgers and French fries. What could you suggest?
3. Monthly weights show a loss of 2 to 3 pounds each month. Should there be a reward system? Could you use motivational interviewing with the family? How would you modify this approach with Alicia?