This case study is about appropriate nutrition interventions, monitoring, and evaluation within the Nutrition Care Process. The nutrition diagnosis is excess energy intake related to spina bifida as evidenced by weight gain over the last year.

Sam is a third-grader in regular classes at his public school. He uses a wheelchair all the time and can transfer from his wheelchair to a chair by himself. He is on a toileting schedule at school with the assistance of a nurse. He participates in modified physical education as part of his physical therapy treatment. He likes to eat with his friends at school. His mother tries to make him cut back at the evening meal and has stopped buying some of his favorite snacks. He is mad at his mother because he likes his snacks after school when he is bored.

Nutrition assessment from Sam’s last visit at the spina bifida clinic at the local hospital showed that he was overweight by measuring his fat stores. Because he cannot stand, his stature was estimated by measuring his length lying down and comparing it with his last length measurement. Standard methods could not be used to measure him, which limits the interpretation of his growth using the CDC growth chart. The chart showed Sam at the 75th percentile in weight for his age, which is not overweight for his age. His rate of weight gain of 8 lb per year, typical for a boy his age, is too fast for his low level of activity. His estimated energy need is 1,100 calories per day due to low activity and short stature, or about two-thirds of the energy needs of others his age. Sam says he does not care about his size or being overweight. His mother is quite concerned that she would not be able to assist him if he fell or needed to be lifted.

Interventions: The nutritionist at the clinic completes a school lunch prescription to reduce Sam’s energy intake from 650 cal to 350 cal per lunch. His meal pattern is adjusted to two meals (breakfast and lunch) and two snacks per day at home, which better fits his low energy needs. Sam is allowed to choose his favorite snack foods to replace his evening meal. Giving him choices about his snacks increases Sam’s sense of being in control and lowers the instances of expressing anger at his mother about snack foods. The clinic nutritionist calls the school to review Sam’s level of activity and confirm that the lunch changes are being implemented. His physical therapist has found after-school swimming lessons and recommends them to Sam’s mother as a way to increase his activity and socialization.

To motivate Sam to pay attention to his eating and weight gain, his teacher and his mother set up a monthly nonfood reward for him if he does not gain any weight. The effectiveness of the plan to cut Sam’s energy intake and increase his activity will be assessed at his next clinic visit, when he will be weighed and have his fat stores measured.

Since Sam does not care about his size or being overweight, why is a diet plan necessary?