Case Study 3: Weight Management for Metabolic Syndrome

DIE 3213 Nutrition Therapy I

Sheila Norris N00095018
Professor Alireza Jahan-mihan
October 27, 2015

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1. Describe the stages of readiness for change, and identify where you think
she falls on this continuum.
The Transtheorectical, or Stages of Change, Model is comprised of six
stages. Although the steps are progressive, a person may regress back to
a previous stage.
1) Precontemplation: The individual has not thought about making a
change.
2) Contemplation: The individual has thought about making a change,
but has done no more than think about it.
3) Preparation: The individual has taken some steps to begin to make the
desired change.
4) Action: The individual has made the change and continues it for less
than 6 months.
5) Maintenance: The individual has continued the behavior for longer
than 6 months.
6) Termination: The individual no longer thinks about the change, it has
become a habit.1
The client has relapsed into the contemplation stage. She has made
numerous attempts in the past to lose weight, but has been unsuccessful
in making it beyond the action stage. Currently she has the desire to
change, but has not taken any action toward reaching her goal other than
this initial visit, which was due to her doctors referral.
In assessing her readiness to change, there are three possibilities: 1) not
ready to change; 2) unsure about change; and 3) ready to change.1
Client falls into the unsure about change category. She wants to set a
good example for her children and she has made past attempts to lose
weight, but she is conflicted about her obligations to her children and her
lack of time. Her previous lack of success in maintaining her weight loss
may have decreased her sense of self-efficacy. Helping the client to move
past these perceived barriers can enable her to move into the
action/ready to change stage.
2. Calculate her BMI. How would you interpret it? How does her waist
circumference measurement add to your assessment?
BMI = Weight (lb) Height (in)2 x 7031
BMI = 178 662 x 703
BMI = 28.7
According to her BMI, client is overweight.

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Clients waist circumference is 38. A waist circumference >35 in

women is equivalent to a BMI of 25 to 34.1
In women, a BMI between 25 and 34.9 and a waist circumference > 35 is
regarded as high-risk for type 2 diabetes, hypertension, dyslipidemia,
coronary heart disease and metabolic syndrome.2
3. What does her history of giving birth to heavier than average babies
suggest?
Her history of giving birth to babies with fetal macrosomia suggests
excessive weight gain during pregnancy and/or pre-gestational or
gestational diabetes.
Excess weight gain during pregnancy can increase the chance of
macrosomia. Clients weight upon the entry of each pregnancy is
unknown, but her history indicates that her BMI was either in the normal
or overweight range. The Institute of Medicine recommends a weight gain
of 25 to 35 lbs. for normal weight women and 15 to 25 lbs. for overweight
women.1 Client gained 40 to 50 pounds during each pregnancy.
Gestational diabetes can result in macrosomia. As glucose passes the
placenta, elevated blood glucose levels expose the fetus to excess
glucose, which can result in increased fetal growth. In turn, women who
have had gestational diabetes are at increased risk for future type 2
diabetes and cardiovascular disease.1
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?
According to the National Cholesterol Education Panel (ATP) III report, the
diagnosis of metabolic syndrome is made when a patient displays at least
three of the following five risk factors:
1) Waist circumference >40 inches in men and > 35 inches in women
2) Serum triglycerides > 150 mg/dL
3) HDL cholesterol < 40 mg/dL in men and < 50 mg/dL in women
4) Blood pressure > 130/> 85 mm Hg
5) Fasting glucose > 110 mg/dL3
Client meets the criteria as she displays all of the risk factors as follows:
1)
2)
3)
4)
5)

Waist circumference 38 inches

Serum triglycerides 189 mg/dL
HDL cholesterol 38 mg/dL
Blood pressure 140/90 mm Hg
Fasting glucose 126 mg/dL

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Metabolic syndrome can be treated with a combination of diet and

physical activity. A calorie-controlled cardio-protective high fiber diet that
avoids extremes in carbohydrate and fat intake is recommended.4 This
diet should include whole grains, low fat dairy, fruits, vegetables, fish,
lean meats, legumes and nuts. Physical activity at a moderate intensity
level for at least 30 minutes on most (preferably all) days of the week is
also recommended. While individual goals for weight loss will vary, a 7%
to 10% decrease in body weight can improve risk factors of metabolic
syndrome.4 Following these recommendations will not only help the client
to lose weight, it can improve the other risk factors as well.
5. What can you do to help her become motivated from within herself to
change her diet and exercise behaviors?
To assist the client in progressing from the unsure about change stage to
the ready to change stage, strategies should include assisting client in
improving self-efficacy, overcoming resistance to change and overcoming
or rethinking perceived barriers to change. Once client is in the ready to
change stage, focus will shift to assisting the client in setting goals and
developing an action plan.
Family plays a central role in the clients life and she seems conflicted
about the amount of time she should be spending with her children and
taking time for herself. She also states that she eats junk food because
that is what her children prefer to eat. Motivational strategies should
include helping her to see that adopting a healthier lifestyle will make her
a better role model for her children and also make it possible for them to
live a healthier lifestyle. Client should also benefit by feeling better,
having more energy and living longer so that she can do more with her
children. Reframing can be utilized to help the client see that increasing
her physical activity and eating healthier does not have to conflict with
the time she spends with her children. Counseling should include having
the client explore healthy activities that she can do with her children that
do not take additional time, such as play/sports activities, coming up with
healthy recipes that the family can prepare together then shopping and
cooking together, or opting for play or taking a walk instead of screen
time.
Client should also be encouraged to find ways to increase physical activity
throughout the day (taking stairs, parking further away, standing versus
sitting). As she is a former athlete, I would encourage her to get back into
some sort of sport or to actively train her children in a sport.
Ways to improve the clients self-efficacy are to teach the client the
components and proportions of a healthy meal and how to do meal

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planning, give her suggestions on ways she can influence her children to
accept healthier foods and make meal preparation a family activity, and
provide her with the tools for the lifestyle changes needed for successful
long term weight loss. Once she is give these tools, client should develop
her own goals and action plan, with assistance and coaching from the
counselor. 1
6. Assuming she becomes ready to take action, identify some initial steps
that she might take to improve her diet.
I would request that she keep a food diary. Client needs to increase
awareness of what she is eating and her eating patterns. Client would
benefit from meal planning and structuring.
Initial steps she might take to improve her diet:
1) Eat breakfast1
2) Opt for healthier snacks - such as fresh or dried fruit, carrot sticks,
nuts or hummus
3) Switch to whole grains
4) Drink water instead of soda
5) Use low-fat milk and salad dressings
6) Healthier desserts such as fruit, yogurt parfaits or oatmeal bars
7) Decrease sodium intake
7. What is the role of physical activity in weight loss and weight
maintenance? How do aerobic activities, strength training and stretching
all contribute to optimal weight management?
Physical activity is key to both weight loss and weight maintenance as it is
the most variable component of energy expenditure. In addition to
directly expending additional energy (calories), physical activity increases
lean body mass, which increases the resting metabolic rate (RMR). This
increase in RMR helps with both weight loss and maintenance as it helps
to offset the reduction in RMR that usually occurs with weight loss.
Additional benefits of physical activity are that it lowers CVD risk and
increases blood flow, HDL levels and insulin sensitivity.1
Aerobic activities improve cardiovascular health, elevate RMR and
increase energy expenditure and fat loss. Resistance training increases
lean body mass, thus it also increases the RMR. It also increases bone
mineral density, which is especially important for women.1
Stretching contributes as it improves range of motion and can help to
prevent injuries. This can help to prevent interruptions in exercise
schedules due to injury or soreness and also improve performance.

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8. What methods would you suggest she could use for self-monitoring?
Initially, she should keep a food diary to increase her awareness and track
what she is eating. This can be accomplished with a small notebook or
with one of many food tracker apps commonly available. She could use
the My Plate website5 to plan or calculate the nutritional content of meals
and to help to distribute calories throughout the day.4 Client should also
weight herself weekly.1
She should keep a daily record of the duration and intensity of her
physical activity. She can incorporate the use of a pedometer or other
tracking device or app.
9. Make suggestions for handling family meals, special occasions and
holidays.
Family meals: She should try to incorporate healthier foods into family
meals. This can be accomplished using small steps such as switching
from white bread to whole wheat, using low-fat milk and salad dressing, or
incorporating a fruit or vegetable into meals. Through counseling, client
can learn to change how she views family meals. Rather than being an
impediment to a healthier lifestyle and a hassle with her children, family
meals can be looked at as an opportunity to not only improve her health,
but also that of her children. She should try to involve her children in the
meal planning and preparation process. This will enable her spend more
time with her children while teaching them how to cook healthy meals,
which will benefit all family members. She should strive to make meal
time a positive experience for everyone, including herself. If time is a
factor, she can prepare meals on the weekends that can be frozen and
reheated during the week.
Special occasions and holidays: It is ok to indulge a little on special
occasions, as long as she exercises portion control and keeps her overall
intake levels in mind. If she knows that these meals will include foods
that she will not be able to resist, she can eat a light, healthy snack before
leaving the house. If she is preparing food for a special occasion, she can
modify recipes using low calorie or low fat ingredients and healthy
cooking methods.
She should also seek the support of her family and friends, especially
during holidays and special occasions. Social support is an important
factor in lifestyle modification.1 She should ask her social network to take
her health goals into consideration in their menu planning, to not push her
to eat high calorie or high fat foods and to support her by helping her
keep on track.

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10.
Write a PES statement based on her initial presentation. How
would you monitor and evaluate the effect of your interventions?
PES: Overweight/obesity related to excessive energy intake and
undesirable food choices as evidenced by BMI of 28.7, waist
circumference of 38 and history of overconsumption of high-fat and/or
energy-dense food or beverage.6
Monitoring/Evaluation:
1. Monitor weight and waist circumference at follow-up visits and have
patient self-report. Client should attain a 0.5 to 1.0 lb per week weight
loss and accompanying decrease in waist circumference.1
2. Monitor clients dietary intake (food diary). Diet should reflect
increases in whole grain, fruit, vegetable and lean protein intake and
decreases in high fat, simple carbohydrate and empty calorie foods.
Client should also eat breakfast most days of the week.1

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One Day Menu5

Breakfast

Lunch

Dinner

Snacks

1 small (6" to 6-7/8" long)

1 large pita (6-1/2" across)
cup Blueberries, raw
Banana, raw
Bread, pita, 100% whole
wheat

4 slice Apple, raw

1 mug (8 fl oz) Coffee,1 tablespoon Mayo, fat-free

1 small breast Chicken,
brewed, regular
breast, boneless, skinless,
baked

4 baby carrot(s) Carrot, baby

1 cup Kashi GOLEAN3 leaves Spinach, raw1 medium scoop Frozen

Cereal
yogurt, vanilla, low fat

1 ounce(s) Cheese, Cheddar or

Colby, low sodium

1 cup Skim milk

5 cracker or wheat wafer

Crackers, 100% whole wheat
(Triscuit, Wheatbury)

cup, chopped or sliced

1 cup Green beans, fresh,
Tomato, raw
cooked (no salt or fat
added)

1 individual packet Sugar

2 ounce(s) cooked Turkey,
1 tablespoon Margarine,
substitute, sucralose-based
white meat, roasted, skin
tub, 100 calories per Tbsp
sweetener (Splenda) not eaten
1 cup (8 fl oz) Water, 1tap
tablespoon Salad
dressing, Ranch, reduced
calorie, fat-free,
cholesterol-free
1 cup Salad, garden,
lettuce, tomato, carrots, no
dressing

1 cup Milk, fat free (skim)

1 cup (8 fl oz) Water, tap

1 cup (8 fl oz) Water, tap

1 small potato Sweet

potato (yam), baked (no
salt added), peel eaten

References
1. Mahan K, Escott-Stump S, Raymond J. Krauses Food and the Nutrition
Care Process. 13th ed. St. Louis, MO: Elsevier/Saunders; 2012.

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2. Nelms M, Sucher K, Lacey K, Roth S. Nutrition Therapy &

Pathophysiology, 2nd ed. Belmont CA: Wadsworth, Cengage Learning;
2011.
3. Emery E. Clinical Case Studies for the Nutrition Care Process. Burlington,
MA: Jones & Bartlett Learning; 2012.
4. Academy of Nutrition and Dietetics Evidence Analysis Library Web site.
http://www.andeal.org. Accessed October 22, 2015.
5. U.S. Department of Agriculture SuperTracker Web site.
http://www.choosemyplate.gov. Accessed October 22, 2015.
6. Academy of Nutrition and Dietetics. International Dietetics & Nutrition
Terminology (IDNT) Reference Manual, 4th ed. Chicago, IL: Academy of
Nutrition and Dietetics; 2013.