Your name:

Jennifer Lail

Date: 10-17-13

CASE STUDY 8. WEIGHT MANAGEMENT FOR METABOLIC SYNDROME

1. Describe the stages of readiness for change, and identify where you think she falls on this continuum. (4 points) The three possibilities of readiness to change include 1) not ready to change, 2) unsure about change and 3) ready to change1. At the not ready to change stage recognizing the barriers, personal and environmental factors and the influence of social norms and attitudes can be important in figuring out how to make an intention to change. The goal for people who are unsure about change should be encouraging and building readiness to begin change. This is the transition from not being ready to deal with a problem to taking steps to correcting it. Counselors with patients in the ready to change stage should work with client to set goals and an action plan in order to facilitate change. I would say that she fluctuates from being ready to change and unsure about change because she states that she wants to set a good example for her children (implying that she know she needs to change and desires to change her behaviors) but that she is too busy to exercise and doesnt want to make separate dinners (implying that she does not think that she can implement the changes)2. She is at the point where she knows change is necessary and knows it is important, but is worried that it will be inconvenient and too hard to make the changes. The role of the nutritionist here will be to encourage her to make behavior changes and illustrate ways that will make the changes easier on her family.
1. 2. Mahan L, Escott-Stump S, Raymond J. Krauses Food and the Nutrition Care Process. Missouri: Elsevier Saunders; 2012. Emery E. Clinical case studies for the nutrition care process. Maine: Jones and Bartlett Learning; 2012.

2. Calculate her BMI. How would you interpret it? How does her waist circumference measurement add to your assessment? (4 points) BMI = 178/(662) x 703 = 28.73 A BMI between 25 and 29.9 is considered overweight so she would fall in the higher end of the overweight category. According to Krause1, a waist circumference over 35in for women is considered high-risk. That is, it is predictive for obesity and chronic disease risk (such as type 2 diabetes mellitus).
1. 2. Mahan L, Escott-Stump S, Raymond J. Krauses Food and the Nutrition Care Process. Missouri: Elsevier Saunders; 2012. Emery E. Clinical case studies for the nutrition care process. Maine: Jones and Bartlett Learning; 2012.

3. What does her history of giving birth to heavier than average babies suggest? (4 points)

According to her medical information, she gained 40 to 50 pounds per pregnancy2. The suggested weight to gain for an overweight woman for pregnancy is 15 to 25 pounds1. The fact that she gave birth to large children (8 and 9 pounds), suggests that she took in too many calories and didnt exercise enough to expend them during the pregnancy. The excessive weight gain was harmful to the children and because she didnt lose much of the weight after, it has been negatively affecting her since.
1. 2. Mahan L, Escott-Stump S, Raymond J. Krauses Food and the Nutrition Care Process. Missouri: Elsevier Saunders; 2012. Emery E. Clinical case studies for the nutrition care process. Maine: Jones and Bartlett Learning; 2012.

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) In order to meet the requirements for metabolic syndrome, a person would have to have three or more of the following: waist circumference of more than 35 in, serum TGs of at least 150 mg/dL, high-density lipoprotein levels less than 50 mg/dL, blood pressure 135/85 mm Hg or higher, or fasting glucose 100 mg/dL or higher1. According to her biochemical data and anthropometric measurements, this patient meets all five of those requirements for metabolic syndrome2. Her waist circumference is 38 in, her serum TG is 189 mg/dL, her HDL level is 38 mg/dL, her blood pressure is 140/90, and her fasting glucose is 126 mg/dL. Diet and physical activity will lower the calorie intake and expend more calories, therefore attempting to balance energy intake with energy expenditure. These lifestyle modifications will gradually reverse most of the symptoms of metabolic syndrome, making the patient a healthier person. If waist circumference, blood pressure, serum TGs and fasting glucose can be lowered, and HDL can be raised, the person will then not be at risk for metabolic syndrome. Eating healthier foods will lower serum TGs and fasting glucose, as well as raise HDL levels. Combine exercise and diet will hopefully lower waist circumference.
1. 2. Mahan L, Escott-Stump S, Raymond J. Krauses Food and the Nutrition Care Process. Missouri: Elsevier Saunders; 2012. Emery E. Clinical case studies for the nutrition care process. Maine: Jones and Bartlett Learning; 2012.

5. What can you do to help her become motivated from within herself to change her diet and exercise behaviors? (4 points) Because she says she wants to set a better example for her children, I would use them as her major motivator for change. I would work with her to make small, plausible changes at first and show her that it is not impossible to make healthy lifestyle choices with a busy schedule. Something as simple as switching white bread out for whole wheat bread, switching snacks to fat-free milk and something other than cookies and donuts, or

replacing cola with a Crystal Light drink at lunch, would be one of the first changes I would suggest, along with including breakfast each day. She is at the unsure of change phase, meaning she knows she needs to make a change, just needs encouragement. Planning a fun activity to do with her kids (such as a trip to the park or swimming in the pool) could help her realize that increasing physical activity can be fun; and if her kids enjoy it, she will be more likely to continue on with these activities. Large changes can be scary and most patients will be unsure where to start and get overwhelmed. Introducing her to the idea of small steps and easy ways to incorporate changes will encourage her to give them a try.

6. Assuming she becomes ready to take action, identify some initial steps that she might take to improve her diet. (4 points) Starting with her first meal, I would explain to her that skipping breakfast is an extremely unhealthy choice, especially if she has a high calorie drink in place of that. Adding a wholewheat bagel with peanut butter with a glass of orange juice in the morning would stimulate her metabolism and hopefully reduce her craving for a midmorning snack of a donut. I would encourage her to keep snacking throughout the day, but replace her unhealthy snacks with food like low-fat cheese sticks, carrots, yogurt or fruit. As mentioned before, for lunch I would suggest she replace white bread with whole wheat bread, and replace cola with water or a zero-calorie drink. For dinner, I would share with her recipes for healthy ways to prepare chicken or turkey and suggest she eats chicken more often than hamburgers during the week. I would suggest she cuts down on the potatoes, and if not, replace them with sweet potato fries or a baked potato. Replacing ranch dressing with a low fat option or vinaigrette would make her salad healthier. For dessert, replacing ice cream or pudding with a fruit salad or yogurt would be a good idea. And for an evening snack, I would suggest she replaces chips and dip with low-butter popcorn.
2.Emery E. Clinical case studies for the nutrition care process. Maine: Jones and Bartlett Learning; 2012.

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) Physical activity is extremely important when it comes to balancing the calories she takes in1. Resistance training helps to increase lean body mass, as well as increasing the ability to use more of her energy intake. Aerobic exercise helps with cardiovascular health, calorie expenditure, and loss of fat. Stretching also burns calories, and should be included as a part of each workout in order to prevent injury and loosen the muscles. Thirty to sixty minutes of moderate workout a day will help facilitate weight loss. Also doing 20 to 30 minutes of high intensity activity 4 to 7 days a week will have similar results. That amount of physical

activity is something she might have to ease into, gradually building up to a long high intensity workout. But it should be stressed to her that every bit helps.
1. Mahan L, Escott-Stump S, Raymond J. Krauses Food and the Nutrition Care Process. Missouri: Elsevier Saunders; 2012.

8. What methods would you suggest she could use for self-monitoring? (4 points) For successful weight loss, it is suggested that patients use a food and activity log and preform regular weigh-ins1. I think the food and activity log would be a good idea for her to complete throughout the day just so she can start being mindful of what she is eating. If she has to record each thing that she eats, it will help keep healthy eating at the forefront of her mind and it will help her monitor exactly what she eats every day. I would also have her do a weekly weigh-in, in order for her to see tangible differences that her healthier lifestyle is changing about her body. Anything more than weekly would be excessive, in my opinion, and could discourage her if she doesnt see large results each day.
1. Mahan L, Escott-Stump S, Raymond J. Krauses Food and the Nutrition Care Process. Missouri: Elsevier Saunders; 2012.

9. Make suggestions for handling family meals, special occasions, and holidays. (4 points) Her main hesitation with making healthy lifestyle changes is that her kids dont want to eat healthy. In order to get the whole family on the same page so she wont have to make two separate dinners, I would suggest to her that she slowly incorporate healthier options into meals. For example, she could make broccoli as a side for dinner instead of potato casserole, but put cheese on the top so the kids will enjoy it more. By slowly changing their unhealthy food choices to healthier ones, the family could get use to the transition and not feel overwhelmed. For special occasions and holidays, I would suggest that she include herself in the meals and eat with everyone, but be mindful of what she eats. Having anything in moderation, especially only for a special occasion, will help her not get discouraged from the stricter diet and not limit her social life. She could also offer to bring a side dish for the meal and make something she knew would be a healthy alternative. That way she can contribute and know that there is something at the meal that she could eat without guilt.

10. Write a PES statement based on her initial presentation. How would you monitor and evaluate the effect of your interventions? (4 points)

Patient is overweight related to calorie intake greater than caloric expenditure, as evidence by patients weight greater than ideal body weight. In order to monitor and evaluate the interventions we come up with, I will have her come in for periodic follow up visits, in order to review her food logs, answer any questions she has and weigh her. Talking with her at the first visit to establish monthly weight loss goals will help us make sure she stays on track to achieve the goals she feels she can comfortably achieve.

Menu Plan based on 1500 calorie diet DAY 1

Breakfast 2 slices whole wheat pancakes 2 tbsp lite syrup 1 cup strawberries (halves) 5 oz fat free milk 2 cups pulled pork, no bun 1 cup spinach 1 tbsp low fat ranch dressing 4 oz chicken 1 cup cooked green beans 1 cup cooked brown rice

Lunch

Dinner

Snacks 1 chocolate pudding cup (throughout day) 1 cup green grapes 1 low fat mozzarella cheese stick DAY 2 Breakfast 1 cup scrambled eggs w/ salsa 1 cup green grapes 1 biscuit 1 tsp butter 1 chicken Caesar wrap 4 oz vanilla yogurt with strawberries 6 oz cranberry juice (zero calories) 1 hamburger on whole wheat bun (95% lean meat) (3oz) 1 cup asparagus, baked 1 sweet potato, baked with skin

Lunch

Dinner

Snacks 1 cup almonds, raw (throughout day) 1 apple 2 cups popcorn, lite butter

DAY 3
Breakfast 2 whole grain pancakes with blueberries 2 tbsp lite syrup 8 oz of coffee, sugar added, lite creamer 1 Peanut butter and jelly sandwich on whole wheat bread 1 cup spinach (with shaved carrots and diced tomatoes) 1 tbsp low fat ranch dressing 1 banana 4 oz salmon, baked 1 cup broccoli, steamed cup corn

Lunch

Dinner

Snacks 1 cup baby carrots, raw (throughout day) 1 low fat mozzarella cheese stick 1 apple

DAY 4
Breakfast 1 whole grain bagel (thin) 2 tbsp peanut butter 1 orange 8 oz coffee, sugar added, lite creamer 1 tuna fish sandwich, whole wheat bread (with lettuce and mayo) 1 apple 4 oz vanilla yogurt with blueberries 4 oz chicken breast, baked 1 cup asparagus 1 cup sweet potato fries, lightly salted

Lunch

Dinner

Snacks 3 cups popcorn, lite butter (throughout day) 1 banana 1 chocolate pudding cup

DAY 5
Breakfast 1 cup scrambled eggs (with pepper) 5 oz fat free milk

1 orange Lunch 1 turkey sandwich, whole wheat bread, American cheese, lettuce, tomato, mustard 1 cup strawberries (halves) 2 cups spaghetti with meat sauce 1 cup green beans 1 cup spinach 1 tbsp low fat ranch dressing

Dinner

Snacks 2 slices watermelon (throughout day) 1 cup almonds, raw

References 1. Mahan L, Escott-Stump S, Raymond J. Krauses Food and the Nutrition Care Process. Missouri: Elsevier Saunders; 2012. 2. Emery E. Clinical case studies for the nutrition care process. Maine: Jones and Bartlett Learning; 2012. 3. Myfitnesspal website. http://www.myfitnesspal.com. Accessed October, 16, 2013.