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Jillian O’NeilKNH 41110/15/13

Case Study #1 – Pediatric Weight Management

1. Current research indicated that the cause of childhood obesity is multifactorial. Briefly

outline the roles of genetics, environment, and nutritional intake in development of

obesity in children.

The cause of childhood obesity is multifactorial – based on the role of genetics, the environment,

and nutritional intake. In regards to genetics, body weight and composition is influenced by

appetite, energy intake, resting energy expenditure, taste preferences, the thermic effect of food,

nonexercise activity thermogenesis (NEAT), and the body’s efficiency to store energy. Research

has shown that each individual has a “genetically determined metabolic set-point” that maintains

a preferred body weight. In addition, it has been shown that having obeses family members

increases one’s risk of obesity. Genetics influences the amount of weight gained, the change in

fat and the change in lead body mass over a period of time. Those in predisposition to obesity

will most likely gain more weight than those not genetically predisposed. Although genetics

plays an important factor, environmental factors are more influential and play a greater

etiological role (Nelms 357). Research has shown that the term of “toxic food environment” is a

cause of childhood obesity. This environment encourages high-energy intake as well as an

increase of portion sizes, fast-food intake (increasing dietary fat intake), convenient and snack

foods, and marketing tactics towards children. It has been shown that when larger portion sizes

are offered, the subject is more likely to consume a higher energy intake (Nelms 257, 258).

Lastly, nutritional intake is another important factor of the development in childhood obesity.

Excessive fat, refined grains, and added sugar intake all lead to obesity. Research has shown that

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an improper nutritional intake leads to an increase in energy intake (often correlated with a

decrease in energy expenditure) and ultimately leading to childhood obesity (Nelms 258).

2. Describe health consequences of overweight and obesity for children.

The presence of heart disease, erosclerotic disease, type 2 diabetes, impaired glucose tolerance

and sleep apnea are associated with overweight and obese individuals. Excess weight is also

connected to high blood pressure, serum levels of total cholesterol, LDL cholesterol and

triglycerides as well as reduced levels of HDL cholesterol. Risk factors – such as hypertension,

family history, impaired fasting glucose, increased LDL cholesterol and decreased HDL

cholesterol – can lead to the health consequences of overweight and obesity for children (Nelms

263, 264). Additional health consequences of overweight and obesity for children and

adolescents includes social discrimination, heart disease (hyperlipidemia, hypertension), type 2

diabetes, and a 70% chance of becoming overweight or obese adults (increased to 80% if one or

more parent is overweight or obese (Nelms 256).

3. Jamey has been diagnosed with obstructive sleep apnea. Define sleep apnea.

According to the NIH Heart, Lung and Blood Institute, sleep apnea is defined as a disorder in

which the individual has one or more pauses in breathing, or shallow breaths, during sleep. These

distinct breathing patterns may last anywhere from a few seconds to minutes and can occur 30

times or more per hour. Once normal breathing restarts, a loud snort or choking sound may

occur. Ultimately, the poor sleeping pattern causes tiredness during the day. Obstructive sleep

apnea – the airway collapses or becomes blocked during sleep – is common in those who are

overweight. In addition, small children with enlarged tonsil tissues in throats may cause

obstructive sleep apnea. Untreated sleep apnea can increase one’s risk of high blood pressure,

heart attack, obesity, stroke, diabetes, heart failure, arrhythmia, and chance of having work or

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driving accidents. Lifestyle changes, surgery and breathing devices can successfully treat sleep

apnea. (National Heart, Lung, and Blood Institute)

4. Explain the relationship between sleep apnea and obesity.

Research has shown that sleep apnea and metabolic syndrome are positively correlated – a rising

BMI shows an increase in sleep apnea severity. Obstructive sleep apnea promotes weight gain,

which ultimately results in glucose intolerance and obesity (Yu 28, 29, 34). Those who are

overweight or obese have an obstructed airway by the large tonsils, enlarged tongue and

increased fat in the neck area – all which press on the airway during sleep when the throat

muscles are relaxed. Sleep apnea is also correlated with hunger and satiety hormones. Those who

have less sleep are more likely to have uncontrollable eating habits, increased blood pressure,

increased glucose intolerance, further weight gain and then worsened sleep apnea (which

ultimately increases the damaged cycle) (Heit).

5. What are the goals for weight loss in the pediatric population?

Based on successful weight management programs for pediatric patients in the past, it would be

of best interest to encourage the flowing points: identify and avoid high-calorie, low-nutrient

foods; develop better exercise habits; reduce sedentary behaviors; follow a healthy, balanced

diet; and maintain a healthy weight over the long-term time period. (Lucile Packard Children’s

Hospital at Stanford)

6. Under what circumstances might weight loss in overweight children not be

appropriate?

For children of ages 5 to 9, a weight loss program may not be appropriate. Instead, it is advisable

to help the child maintain her weight and allow her to grow into her weight. (Griffin). In

addition, over restrictive diets for weight loss are not usually appropriate or children. This type

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of diet generally doesn’t supply the proper growth needs for the child. Lastly, weight loss may

not be applicable for those currently with a terminal illness or severe disease – such as cancer.

(Tamborlane 138)

7. What would you recommend as the current focus for nutritional treatment of Jamey’s

obesity?

For Jamey’s nutritional treatment of obesity, the current focus should be concentrated on overall

energy intake and expenditure. At age 10, she is in the range of implementing a weight loss

program and maintaining her current weight to “grow” into. I would recommend encouraging

energy expenditure by increasing her physical activity level from generally low to active. With

this recommendation and based on her 24-hour recall, I would recommend the focus for

nutritional treatment to include an overall healthier diet – decrease in saturated fats and an

increase in fresh fruits and vegetables. (Tamborlane 138; Lucile Packard Children’s Hospital at

Stanford; Nems 5).

8. Evaluate Jamey’s weight using the CDC growth carts provided (p.8): What is Jamey’s

BMI percentile? How is her weight status classified? Use the growth chart to determine

Jamey’s optimal weight for height and age.

Jamey’s BMI is 24.9. According to Nelms, classifying pediatric BMI is used based on the

percentiles. A weight, of 115 pounds (52.3kg), puts her at a weight status of the 95th percentile

for 10 year old girls. A percent of 95 or greater is at the BMI classification of “obese.” For a

height of 57” (145cm), she is at the 80th percentile for her age. For a 10 year old girl, in the 5th to

85th percentile (a classification of “healthy weight”), her optimal weight would be would be 57 to

87 pounds (34.1 kg). (Nelms 8 – a Case Study approach; Nelms 247)

Calculations:

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115 lb / 2.2 = 52.3kg 57 lb / 2.2 = 25.9kg 87 lb / 2.2 = 39.5kg

9. Identify two methods for determining Jamey’s energy requirements other than indirect

calorimetry, and then use them to calculate Jamey’s energy requirements.

Aside from indirect calorimetry, Jamie’s energy requirements can be determined using

equations. Estimated Energy Requirement, EER, can be used to estimate the average dietary

energy intake needed to maintain a person’s current weight. Since Jamey is of a young age, it

may be recommended to maintain her current weight and have her “grow into” this weight.

Jamey’s EER is 2025 calories (a recommended range of 2000 to 2500 calories). Jamey may need

to lose weight since she is in the high percentile for her age. With this, Total Energy Expenditure

(TEE) may be used for weight maintenance in kilocalories per day for overweight children and

adolescents. Jamey’s TEE is 1920 calories (a recommended range of 1900 to 1950 calories).

(Nelms 241, 242, 243)

Calculations:

Weight: 57” * 2.54 / 100 = 1.45m

Height: 115 lb / 2.2 = 52.3 kg

EER = TEE + Tissue Deposition

EER = 135.3 - 30.8 x age + PA (10.0 x weight + 934 x height) + 20

EER = 135.3 - 30.8 x 10 + 1.16 (10.0 x 52.3 + 934 x 1.45) + 20

EER = 2025 calories

TEE = 389 – 41.2 x age + PA x 15.0 x weight + 701.6 x height

TEE = 389 – 41.2 x 10 + 1.18 x 15.0 x 52.3 + 701.6 x 1.45

TEE= 1920 calories

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10. Dietary factors associated with increased risk of overweight are increased dietary fat

intake and increased calorie-dense beverages. Identify foods from Jamey’s diet recall

that fit these criteria.

According to her 24-hour recall using fitday.com, Jamey consumes foods high in dietary fat and

calorie-dense beverages. Her diet recall items that fit into the criteria of foods high in dietary fat

include: the breakfast burrito, whole milk, cream, bologna and cheese sandwich, Fritos corn

chips, Twinkies, peanut butter, friend chicken, mashed potatoes, fried okra and popcorn. Her diet

recall items that fit into the criteria of high calorie-dense beverages include: whole milk, cream,

Coca-Cola and sweet tea. (Nelms 5, FitDay)

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11. Calculate the percent kcal from each macronutrient and the percent kcal provided by

fluids for Jamey’s 24-hour recall.

Jamey’s 24-hour recall (using www.fitday.com) displayed an intake of 4,785 calories in total.

She consumed 559.8 grams of carbohydrates (2,232 calories), which is 47% of her total intake.

She consumed 200.1 grams of fats (1,776 calories), which is 37% of her total intake. She

consumed 191.5 grams of protein (781 calories), which is 16% of her total intake. Her fluid

intake consisted of 8oz whole milk (146 kcal), 4 oz apple juice (58 kcal), 6oz coffee (2 kcal), ¼

cup cream (78 kcal), 8oz whole milk (146 kcal), 12 oz whole milk (220 kcal), 20 oz sweet tea

(198 kcal) and 12 oz Coke (160 kcal). In total, her fluid intake was 1,008 calories equaling to

21.0% of her total calories. (Nelms 5, FitDay)

Calculations:

Fluid Intake Calorie Total = 146 + 58 + 2 + 78 + 146 + 220 + 198 + 160 = 1,008 calories

1008 fluid calories / 4785 total calories = 0.21065 * 100 = 21.0% kcal

*Fitday.com images from Question 10 were used in the evaluation of Question 11*

12. Increased fruit and vegetable intake is associated with decreased risk of overweight.

What foods in Jamey’s diet fall into these categories?

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Jamey’s diet was not high in fruit and vegetables. Although these foods were not prepared in a

healthy way, her diet consisted of potatoes (a starchy vegetable) as well as okra and corn. In

addition, she consumed apple juice – which may fall into the fruit category if fruits depending

upon the nutritional information. She did not reach the USDA’s recommended daily intake

amount of fruits and vegetables – 2 cups of fruit and 2.5 cups of vegetables. (Nelms 5,

Thompson 53).

13. Use the Fitday.com to generate a customized daily food plan. Using this eating pattern,

plan a 1-day menu for Jamey. (Use fitday.com to analyze/make a customized meal plan

for the client)

Breakfast:

Breakfast Burrito: 1 whole egg, 1 small tortilla, 1oz low-fat Swiss cheese, 0.15 cup tomatoes, 0.15 cup pepper, 0.25 cup spinach

Beverage: 8oz skim milk, 8oz herbal teaSide: 1 small wedge of cantaloupe

Lunch

Sandwich: 2 regular slices of whole wheat bread, 4 thin slices Turkey, 2 slices of lowfat American Cheese, 1 TBSP hummus

Beverage: Water (8 oz minimum)Side: 1oz sweet potato chips, 0.5 cup pineapple, 0.5 cup cucumber slices

Afternoon Snack

Cracker Sandwich: 3oz whole wheat/bran crackers, 1 TBSP reduced fat peanut butter, 1 TBSP jelly

Beverage: 8 oz skim milk

Dinner

Entrée: 4oz baked chicken breast, 1 small sweet potato (baked without salt added), 1 cup okra baked

Beverage: 8oz unsweetened tea

After Dinner Snack

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Snack: 1.5 oz popcorn (94% fat free, microwavable)Beverage: 12 oz unsweetened carbonated water

*This 1-day menu provides Jamey with 1,944 calories – 239.4g carbohydrates, 124.3 g protein, and 58.0g fat. See photo for item-by-item analysis

Her TEE calorie recommended range is 1900 to 1950 calories. This daily menu provides 1,944 calories – an acceptable amount for the recommended range.

(FitDay)

14. Now enter and assess the 1-day menu you planned for Jamey using the fitday.com

online tool. Does your menu meet macronutrient and micronutrient recommendations

for Jamey?

The planned 1-day menu (shown in question 13) meets Jamey’s requirements for energy (total

calories). The TLC plan recommends an intake of 50-60% carbohydrates, 25-35% fat, and 15%

protein. In addition, it recommends 20-30g fiber and less than 2,400mg of sodium. This menu

provides 25% fat, which is within the recommended range. As for carbohydrates, it is 48% which

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is just shy of the 50-60% recommended range. I believe that it’s okay for this value to be slightly

lower than the recommended value because she is definitely taking in the minimum amount for

daily function as well as she is currently overweight. This slight decrease in carbohydrate intake

will help her maintain her weight as well as “grow into” her current weight over time. This diet

is slightly high in protein – 26% in comparison to the recommended “remaining” or 15%. I

believe that this elevated value is beneficial for this particular case because of Jamey’s current

health. With her change in lifestyle behaviors, her clinical team will encourage an increase in

physical activity (which will need a little extra protein) as well as protein is important for

growth. If the doctor stated this value was too high, we could substitute a serving of milk for

water because she would still be consuming enough calcium needed for her diet. Lastly, this diet

provides 3,410mg of sodium in comparison to her previous diet of 1,169mg. In addition, her diet

provides 31.7g of dietary fiber, just over the recommended amount of 20-30 but still beneficial

for a healthy diet.

In comparison to Jamey’s previous diet, her macronutrient amount would decrease

significantly. The initial diet analysis (of the 24-hour recall) provided Jamey with 4,785 calories,

200g fat, 560g carbohydrates and 192g protein. This new 1-day menu I have planned would

provide Jamie with 1,944 calories, 58g fat, 239g carbohydrates and 124g protein. Overall, this is

a decrease in 2,841 calories, 142g fat, 321g carbohydrates and 68g protein.

Calculations:

4785 - 1944 = 2841 calories

200 - 58 = 142 g fat

560 - 239 = 321 g carbohydrates

192 – 124 = 68 g protein

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(FitDay)

15. Why did Dr. Lambert order a lipid profile and blood glucose tests? What lipid and

glucose levels are considered altered (i.e., outside of normal limits) for the pediatric

population? Evaluate Jamey’s lab results.

Dr. Lambert ordered a lipid profile and blood glucose tests to measure her biochemical data.

Routinely measuring biochemical data is important to “keep an eye” out for further health risks

and problems. Obese individuals have a greater change of having an elevated serum level of total

cholesterol, low-density lipoprotein cholesterol, and triglycerides as well as a decreased serum

level of high-density lipoprotein cholesterol. These factors put an individual at a high risk for

coronary heart disease. In addition, blood glucose tests are important factors of the biochemical

data because type 2 diabetes is three times more likely in obese individuals. Excess body fat is a

major risk for metabolic syndrome. High levels of free fatty acids can cause insulin secretion

from the pancreas’ beta-cells which ultimately cause glucose resistance and increase hepatic

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glucose production. These complications can lead to hyperglycemia, impaired glucose tolerance,

hyperinsulinemia, and type 2 diabetes development. Weight loss may aid in the impaired glucose

tolerance levels. Both lipid profiles and blood glucose tests cross over with Type 2 Diabetes risk.

(Nelms 253). Altered lipid levels are glucose values outside of the reference range of 70 to 110

mg/dL. Altered lipid levels are values outside of the reference ranges for: cholesterol (greater

than 170 mg/dL), HDL cholesterol (less than 55mg/dL), LDL cholesterol (greater than 110

mg/dL), an LDL/HDL ratio (of greater than 3.22), and triglycerides (greater than 150 mg/dL).

Jamey’s lab results showed an increased glucose level of 112 mg/dL, a decreased HDL level of

34 mg/dL, and an increased LDL/HDL level of 3.23 (Nelms 6).

16. What behaviors associated with increased risk of overweight would you look for when

assessing Jamey’s and her family’s diets. What aspects of Jamey’s lifestyle place her at

increased risk for overweight?

When assessing the Whitmer family’s diet and behaviors, I would encourage the entire family to

make lifestyle changes. First, both Jamey’s mother and grandmother have type 2 diabetes – I

would look for improvements on their overall diet and physical activity levels to decrease their

health implementations. Secondly, Jamey’s medical record shows that her parents purchase and

prepare the food. Her parents should become nutritiously aware of a healthy diet in order for

Jamey to have healthy, prepared foods versus the foods she is currently consuming. Nutrition

education would be helpful in this change. Her family is currently consuming a diet high in fats,

cholesterol, added sugars, refined grains, and excess calories. Lastly, Jamie plays video games

and enjoys reading, which contribute to her physical activity level of low. Reading is an

important factor in educational development so I would encourage the reading with a maximum

time limit of 1.5 hours per day (to start with). To increase her physical activity level, I would

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encourage the entire family to engage in physical activity together – such as going for walks

together or playing outdoor games. Aspects of Jamey’s lifestyle that put her at risk for being

overweight include: high calorie, low nutrient foods; sedentary behaviors; increased weight gain;

and not following a healthy, balanced diet (Nelms 4,5; Lucile Packard Children’s Hospital at

Stanford).

17. You will talk with Jamey and her parents, who are friendly and cooperative. Jamey’s

mother asks if it would help for them to not let Jamey snack between meals and to

reward her with dessert when she exercises. What would you tell them?

Although her parents can continue to allow Jamey to snack between meals, I would tell them to

make the snacks healthier. Her current after school snack includes a peanut butter and jelly

sandwich with 1.5 cups of whole milk – this is a meal in itself. It would be of best interest to

substitute this high calorie, high fat “snack” with a smoothie filled with 1 cup fruit, ½ cup

vegetable, and 1 cup of skim milk or Greek yogurt. I chose these options to increase her fruit and

vegetable intake as well as decrease her fat and calorie intake. As for her after dinner snack, it

would be advisable to substitute the Coca-Cola for water or “kid-friendly” nighttime tea –

decreasing her calorie and added sugar levels. In addition, the popcorn should not have added

salt or sugar added. Seasonings, such as spices, may be added to plain, white popcorn. In regards

to desserts as a reward with exercise, I would not encourage this. Instead, I would support non-

food related rewards. An appropriate “gift” would be athletic socks, sneakers, or workout apparel

that would encourage Jamie to continue the physical activity. Adding calories to her diet would

not be recommended. (Nelms 5).

18. Identify one specific physical activity recommendation for Jamey.

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A recommendation for Jamey’s physical activity would be to walk 1.75 miles within 35 minutes

(20 minutes/mile) with her family before dinner. This exercise prescription would increase

Jamey’s energy expenditure at a less vigorous level. As Jamey’s physical fitness increases, she

can move to activities of a more vigorous level. (Nelms 267)

19. Select two nutrition problems and complete PES statements for each.

Jamey’s Nutrition problems:

Excessive energy intake NI-1.3

Excessive fat intake NI-5.6.2

Excessive mineral intake NI-5.10.2 Sodium(7) 10736

Overweight NC-3.3

(Academy of Nutrition and Dietetics)

A. Excessive Calorie Intake

Excessive caloric intake of 4,785 calories as related to lifestyle-diet choices as

evidence by a BMI of 24.9 and weight history of 115 pounds.

B. Excessive Fat Intake

Excessive fat intake of 200g as related to lack of nutrition knowledge as evidence

by diet history.

(A Case Study Approach 5)

(Academy of Nutrition and Dietetics, A Case Study Approach 5)

20. For each PES statement written, establish an ideal goal (based on signs and symptoms)

and an appropriate intervention (based on etiology).

A. Excessive Calorie Intake

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Ideal goal: maintain overall body weight by improving lifestyle choices – an

example for Jamie would be to increase her daily activity level as well as stick to

a modified caloric diet.

B. Excessive Fat Intake

Ideal goal: make healthier choices when eating by improving Jamey’s, as well as

Mr. and Mrs. Whitmer’s, knowledge about healthy eating habits – an example

would be to attend educational nutrition counseling sessions with a Registered

dietitian to learn about basic nutrition that can be applied to the entire family’s

lifestyle. In addition, the family can attend a “healthy cooking” seminar together

to learn the healthiest ways in preparing everyday foods.

(Evidence Library)

21. Mr. and Mrs. Whitmer ask about using over-the-counter diet aids, specifically Alli

(orlistat). What would you tell them?

According to the Evidence Analysis Library, is a gastrointestinal tract lipase inhibitor that can

decrease fat absorption by up to 30%. Although clinical studies have shown that orlistat may be

helpful for obese adults, the long term effects and tolerability has not been studied as a treatment

for adolescents. It is thought that orlistat may be helpful for adolescents in conjunction with diet,

exercise, and behavioral therapy – which is why the FDA has approved the over-the-counter

drug for those aged 12 and older. Although studies have shown the positive effects of orlistat,

studies have shown a decrease in BMI and similar changes in lipid or glucose levels in both the

treatment and placebo groups. Therefore, I would encourage the patient to try lifestyle,

behavioral changes first before choosing a daily drug. In addition, Jamey is only ten years old –

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so, choosing a change in lifestyle behaviors before heading to pills (in two years, if needed)

would be advisable. (Evidence Analysis Library).

22. Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey. Using the EAL,

what are the recommendations regarding gastric bypass surgery for the pediatric

population?

According to the Lucile Packard Children’s Hospital at Stanford, weight loss surgery may be

acceptable for adolescents with a BMI greater than 35 in addition to one or more obesity-related

healthy issues. Surgery is only recommend when other weight loss methods were initially

unsuccessful. In addition, patients must be able to commit to follow-up visits as well as lifestyle

changes (including daily vitamin and mineral supplements; consuming a low-calorie, low-

carbohydrate diet; regular exercise, as well as take post-surgery medication for six months).

(Lucile Packard Children’s Hospital at Stanford.

23. What is the optimal length of weight management therapy for Jamey?

According to the Academy of Nutrition and Dietetics’ Evidence Library, a weight management

therapy for Jamey’s case should be “at least three months or until initial weight-management

goals are achieved.” Some programs may take over one year but the minimum recommended

duration is three months – to allow all aspects of therapy to occur and properly analysis initial

progress. (Evidence Library)

24. Should her parents be included? Why or why not?

Jamey’s parents should be included in her weight management therapy. As stated in her medical

record, her parents both purchase and prepare her meals. As they attend the sessions with her,

they will become nutritionally knowledgeable and be able to apply the healthy lifestyle behaviors

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to Jamey’s, as well as their own, daily plan. In addition, since Jamie is below the age of 18, she

will need parental guidance in making positive changes.

25. What would you assess during this follow-up counseling session?

In a follow-up counseling session, I would assess Jamey’s overall progress from the last time we

met until the current moment. First, I would assess her current weight as well as review any

blood work her doctors have called in (if applicable). Although my main focus is dietetic related,

I am also of concern for how the energy intake is affecting her blood levels – focusing on her

total cholesterol, HDL, LDL and triglyceride levels. Her previous diet was high in cholesterol

and dietary fat, which is why these blood values would be of concern. In addition, I would assess

her dietary recall. In our first counseling session, I would have requested for Jamey (with the

help of her parents) to create a daily log containing her food and exercise agenda – including

type of food, portion sizes, activity level and activity duration. If the family is able to use

www.fitday.com, I would encourage them to do so – that way I can receive a print out of the

food analysis with portion sizes, nutritional amounts as well as macronutrient and micronutrient

amounts. Although Jamey is considered overweight for her age, it is not advisable for her to try

to lose weight. At this stage in her life, her medical team would encourage maintaining her

current weight and allow her to “grow into” the weight. As for nutritional education, I would

instruct the Whitmer family on the continuing importance of healthy eating and portion control.

By reviewing the food log of the past weeks, I can show exactly where the “good” and “bad”

choices were made. I would also encourage the family to follow the TLC plan (as evaluated in

question 14. Another benefit of using FitDay would be that the family can see the exact amount

of nutrients they are consuming with each meal – providing instant feedback and “advice” for

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future, upcoming meals. This progress will show me where I need to focus the new goals for the

upcoming weeks prior to the third counseling session.

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Resources

Academy of Nutrition and Dietetics (2013). International dietetics and nutrition terminology (IDNT) reference manual: Standardized language for the nutrition care process. Chicago, IL: Academy of Nutrition and Dietetics.

Evidence Summary: Use of Orlistat in the Treatment of Childhood Obesity. (n.d.). Evidence Analysis Library. Retrieved October 11, 2013, from http://andevidencelibrary.com/evidence.cfm?ecidence_sumary_id=250452

"Executive Summary of Recommendations." Evidence Library. N.p., n.d. Web. 12 Oct. 2013. <http://andevidencelibrary.com/topic.cfm?cat=3013&auth=1>.

Griffin, R. (n.d.). Weight Loss for Kids: Weight Loss Programs and Recommendations for Overweight Children. WebMD – Better Information. Better Health.. Retrieved October 11, 2013, from http://www.webmd.com/parenting/raising-fit-kids/weight/weight-loss-reommendations?page=1

Heit, J. (2008, August 25). Obesity and Sleep Apnea: What’s the Connection?. Health Central. Retrieved October 12, 2013, from http://www.healthcentral.com/obesity/c/4!connection/

Nelms, Marcia. Medical Nutrition Therapy: A Case Study Approach. 4th ed. Stamford, Connecticut: Cengage Learning, 2013. Print

Nelms, Marcia Nahikian. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA: Wadsworth, Cengage Learning, 2011. Print.

Pediatric Weight Control Programs for Child Weight Management. (n.d.). Lucile Packard Children’s Hospital at Stanford LPCH: Northern California Children’s Hospital. Retrieved October 11, 2013, from http://www.ipch.org/clinicalSpecialitiesServics/ClinicalSpecialities/centerHealthyWeight/ppwcp/our-services.html

Tamborlane, W. V., & Weiswasser, J. Z. The Yale guide to Children’s Nutrition. New Haven: Yale University Press, 1997. Print.

Thompson, J. & Manore, M. Nutrition An Applied Approach. 3rd ed. Boston: Pearson Education, 2012. Print

“What is Sleep Apnea?” NIH Heart, Lung and Blood Institute. N.p., (10 July 2012). Retrieved October 12, 2013, from http://www.nibi.nih.gov/health/healthtopics/topics/sleepapnea/

Yu, J., & Berger, P. (2011). Sleep Apnea and Obesity. South Dakota Medicine: The Journal Of The South Dakota State Medical Association, Spec No28-34.