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Case Study #8
Weight Management for Metabolic Syndrome Medical Nutrition Therapy (DIE 3213) Emily Rose Greco, B.S. October 17, 2013

1. Describe the stages of readiness for change, and identify where you think she falls on this continuum. (4 points) There are three possibilities for readiness to change which are not ready to change, unsure about changing, and ready to change.1 I believe this client is in the middle unsure about changing because while she has come to counseling she says she does not have time to exercise and she does not want to have to make separate meals for her children and herself. I think if she were truly at a stage of ready to change she would be willing to come up with solutions right away rather than make any kind of excuses. 2. Calculate her BMI. How would you interpret it? How does her waist circumference measurement add to your assessment?(4 points) Wt: 178 lbs/2.2 = 80.91 kg Ht: 56 = 66 in = 66*2.54 = 167.64 BMI = 80.91/ (1.6764)2 = 28.79 Waist circumference: 38 inches Her BMI is in the overweight range and her waist circumference is higher than 35 inches indicating two risk factors for metabolic syndrome.1 Waist circumference larger than 35 inches in women strongly correlates with insulin insensitivity.1 3. What does her history of giving birth to heavier than average babies suggest?(4 points) Heavier than average babies suggest that the mother was overweight before and during the pregnancy, had poorly controlled diabetes in pregnancy, and excessive weight gain in pregnancy (over 44 lbs which she did gain 40-50 lbs with each pregnancy).6 Also it does not mention whether or not she breastfed after giving birth, and based on her weight retention it appears she did not breastfeed because postpartum weight retention tends to be slightly less in women who breasted for at least 6 months after pregnancy.6 It has also been found that high blood levels of insulin and leptin during pregnancy have led to increased weight gain during pregnancy (leading to insulin resistance and remaining overweight in her future).6 4. Does she meet the criteria for this syndrome according to the National Cholesterol Education Panels Adult Treatment Panel III? How is metabolic syndrome treated with diet and physical activity?(4 points) She does meet the criteria for metabolic syndrome because according to NCEP ATP Panel III guidelines, displaying three out of the five risk factors classifies a person as having metabolic syndrome.2 Risk factors include abdominal obesity (waist circumference greater than 40 inches in men and greater than 35 inches in women), triglyceride levels greater than or equal to 150 mg/dL, HDL cholesterol being less than 50 mg/dL (for women), blood pressure being greater than 130/85 mmHg, and fasting plasma glucose being greater than 100 mg/dL. 2 This client meets all criteria for metabolic syndrome.

According to the American Heart Association and National Heart, Lung and Blood Institute, metabolic syndrome is treated by diet and physical activity encouraging weight loss as the number one criterion. This would include encouraging 30-60 min of moderate-intensity aerobic activity most days of the week (preferably daily), eating less than 7% of the calories from saturated fat, reduce trans fat, reducing dietary cholesterol, consuming between 2535% of the calories from fat (most fat being unsaturated), simple sugars being limited, reducing sodium, increasing consumption of fresh fruits, vegetables, and low-fat dairy products, and decreasing caloric intake by 500-1000 calories per day in order to lose 710% from baseline body weight during a period of 6-12 months.3 These lifestyle interventions can make a positive impact on this clients impaired fasting glucose, high blood pressure, excessive body weight, and levels of triglycerides and HDL cholesterol. 5. What can you do to help her become motivated from within herself to change her diet and exercise behaviors?(4 points) In order for her to become motivated from within herself it is important to understand her frame of reference using reflective listening and expressing acceptance and affirmation, empathy, bringing forth and discerningly reinforcing her own self-motivational statements, recognizing her obstacles, concerns, and intentions to change (and ability to change), not jumping ahead of her (taking small steps toward a larger goal), and acknowledging her freedom of choice and self-direction.4 Since she has expressed that she would like to set a good example for her children, I would ask her what kinds of foods she thinks of as setting a good example for them. From there we could come up with combinations of foods that the children may possibly like to eat so that she would not have to make separate dinners. I would also ask her how she feels about perhaps taking a short walk (20-30 min) with her kids after dinner in order to increase physical activity. I would try to help her come up with small changes and goals so that it will be easier and less intimidating for her to make further changes as times goes on. 6. Assuming she becomes ready to take action, identify some initial steps that she might take to improve her diet.(4 points) Since the main goal in metabolic syndrome is to reduce weight, her diet would need to be modified in order to reduce her caloric intake.3 Since she skips breakfast, I would ask her for her reasoning behind it and explain to her the importance of eating breakfast. I would ask if she can think of any foods she could possibly eat in the morning that could fill her up (suggesting foods with a lot of fiber). I would ask if she would be willing to change her mid morning snack and afternoon snack to something a bit healthier at least a few times per week (maybe some fruit and crackers or vegetables and hummus). Since she drinks 2% milk, I would ask how she felt about drinking 1% or skim instead to save some calories and saturated fat. I would also ask how she felt about eating whole wheat bread as opposed to white bread. Since she drinks cola, I would ask if she would be willing to try diet cola instead in order to reduce calories and added sugar. As for dinner I would ask how she felt about eating sweet potatoes as opposed to regular white potatoes or potato salad, and increasing the size of the salad to fill up faster and reduce calories and eat a lesser amount

of meat. She eats her salad with ranch dressing, so I would ask how she felt about trying an oil based dressing or reduced calorie dressing in order to save calories and increase consumption of healthy fats (I would also discuss with her about how eating fat free dressing is actually not as good as a low fat one because the fat helps absorb vitamins from the salad). She likes to eat desserts such as ice cream, pudding, or jello, so I would suggest that she eat diet pudding, sugar free ice cream, or sugar free jello. As for her evening snack I would ask if she would reduce the amount of times per week she eats an evening snack and also ask if shed be willing to drink a low-calorie drink as opposed to juice and a food lower in calories than chips and dip. 7. What is the role of physical activity in weight loss and weight maintenance? How do aerobic activity, strength training, and stretching all contribute to optimal weight management? (4 points) During the first six months the focus of weight loss is on reducing caloric intake through the diet. Physical activity plays less of a role in this deficit, but during the next six months, however, the focus changes from weight loss to weight maintenance making physical activity much more crucial. Following this phase, further weight loss may be an option.1 Aerobic, strength training, and stretching are all very important in order to achieve optimal weight management. Resistance training increases lean body mass which in turn increases resting metabolic rate and the ability to use more energy intake. It also increases bone mineral density (especially for women).1 Aerobic exercise is another important factor in increasing resting metabolic rate, and it is also great for caloric expenditure, body fat loss, and cardiovascular health. Stretching is important in order to prevent injuries and increasing flexibility. Most physical activity benefits can be gained by moderate intensity exercise accumulated in short durations (20-30 minutes) four to seven days per week.1 8. What methods would you suggest she could use for self-monitoring?(4 points) Since the purpose of self-monitoring is to increase self awareness of behaviors and identifying obstacles to change, I would suggest keeping a diary/log of dietary intake and physical activity, logging weight every day, perhaps even set a phone reminder/alarm, or utilizing an internet logging website (MyPlate for example).1,4 I would also suggest that since her fasting blood glucose indicates prediabetes that she test her blood sugar three times per week in order to make sure it does not develop into diabetes. She could also buy a blood pressure machine in order to check her blood pressure since that too is elevated. She could directly see herself how her lifestyle changes are impacting these numbers. Keeping track of her waist circumference (using a tape measure) would be another great option trying to get it less than 35 inches. 9. Make suggestions for handling family meals, special occasions, and holidays.(4 points) According to a study by Baker and Kirschenbaum, participants that maintained highly consistent self monitoring during holidays and special occasions were the only group able

to have any weight loss during the ten weeks of the study.5 The least consistent selfmonitoring group was the only group that consistently gained weight. They suggest it may take nearly perfect self-monitoring to buffer the effects of certain high-risk situational challenges. So I would suggest to this client that she be even more vigilant with keeping a food diary or internet log, perhaps even have some kind of application on her smart phone (if she has one) in order to make it even more accessible to logging her diet, physical activity, and weight. If she travels during the holidays, suggest to her that she bring her scale so that she does not lose track of her weight. 10. Write a PES statement based on her initial presentation. How would you monitor and evaluate the effect of your interventions?(4 points) Metabolic syndrome related to stress, weight gain, and low energy levels as evidenced by abdominal obesity (waist circumference greater than 35 inches), high BMI, elevated triglyceride levels, lowered HDL cholesterol levels, elevated blood pressure, and elevated fasting plasma glucose level.8 I would monitor the effects of these interventions by testing her blood glucose levels biweekly, and having biweekly counseling sessions. I would go over her logs of blood pressure, weight loss, physical activity, and blood glucose level logs. Based on these lab values and her concerns I would modify these intervention strategies I would perhaps help her come up with different creative meal plans if she felt like she was running out of ideas. I would give her handouts and sample menus for meals that could possibly fit in with her schedule as well. I would ask her about her physical activity levels and see if she would be able to afford a personal trainer at least once per month in order to give her more ideas for working out. If this is not possible, I would suggest more ways in order for her to get moving, for example asking a friend or neighbor to walk with her at some point during the day in order to have an extra boost of motivation from another person. In order to monitor and evaluate effectiveness, weight loss must be observed along with (hopefully) improved blood glucose levels, waist circumference, and blood pressure.

Menu Plan7: For this menu plan I made sure to keep in mind the clients taste for peanut butter and jelly sandwiches for lunch, fruit, milk, soda, and dessert after dinner, as well as her dietary pattern of eating both a morning and evening snack

Breakfast
1 fruit(s) Clementine, raw 1 cup(s) Cereal, hot, oatmeal, one minute, prepared, Quaker 1 cup(s) Milk, fluid, partly skimmed, 1% M.F.

Morning Snack
1 bar(s) Granola bar, chewy, low fat

Lunch
1.5 tbsp(s) Peanut butter, reduced fat 1 tbsp(s) Sweets, jellies, reduced sugar or no sugar, home preserved 2 tbsp(s) Salad dressing, ranch dressing, reduced fat 2 slice(s) (35g) Bread, whole wheat, commercial 10 fruit(s) Grape, red or green (European type, such as Thompson seedless), adherent skin, raw 2 cup(s) Lettuce, cos or romaine, raw 1 can(s) (355ml) Carbonated drinks, cola w/ aspartame

Dinner
1 cup(s) Milk, fluid, partly skimmed, 1% M.F. 5 oz Tilapia, baked or broiled 0.5 cup(s) Grains, quinoa, cooked 2 cup(s) Lettuce, cos or romaine, raw 1 cup(s) Carrot, cooked 2tbsp(s) Salad dressing, ranch dressing, reduced fat 5 oz Dessert, gelatin, dry mix, calorie reduced, w/ aspartame, prepared w/ water

Evening Snack
5 small stalk(s) (13cm long) Celery, raw 1 tbsp(s) Hummus, homemade

References 1. Mahan LK, Escott-Stump S, Raymond JL. In: Alexopoulos Y, Frazier DM, eds. Krauses Food and the Nutrition Care Process Thirteenth Edition. St. Louis, MO: Elsevier Saunders; 2012: 331, 470-471, 474, 477-478. 2. Nelms MN, Sucher K, Lacey K, et al. In: Cossio Y, Williams P, Feldman E, et al. Nutrition Therapy and Pathophysiology Second Edition. Belmont CA: Wadsworth Cengage Learning; 2011: 302-303. 3. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005; 112:2735-2752. 4. Artinian NT, Fletcher GJ, Mozaffarian D, Kris-Etherton P, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 2010; 122:406-441. 5. Baker RC, Kirschenbaum DS. Weight control during the holidays: highly consistent selfmonitoring as a potentially useful coping mechanism. Health Psychol. 1998;17:367370. 6. Brown JE, Isaacs JS, Krinke UB, Lechtenberg E, et al. In: Williams P, Rose N, Feldman E, eds. Nutrition Through the Life Cycle Fourth Edition. Belmont CA: Wadsworth Cengage Learning; 2011: 101, 107. 7. Eatracker.ca Web Site. www.eatracker.ca. Accessed October 12, 2013. 8. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutriton Care Process, 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013.