Morgan McNeal

10/27/15
DIE 3213 Nutrition Therapy 1
Michelle Elkadi

Case Study #3

1. Describe the stages of readiness to change, and identify where you think she falls on this
continuum.
The three stages of readiness to change are: Ready to change, unsure about change, and
not ready to change.1 Each of these categories can be identified by determining which
stage the client/patient falls into by using the Trans theoretical model, which includes
precontemplation (not thought about change), contemplation (thought about making a
change, but has not done anything to make it happen), preparation (taken some steps to
change), action (made change for less than 6 months), maintenance (continued to change
for over 6 months), and termination (no longer thinks about the change, it is now a
habit).1
The patient appears to be in the contemplation stage because she has thought about losing
weight and exercising more, but has not taken the steps to complete the change. She has
also stated that she wants to set a good example for her kids, but does not have the time to
exercise. This shows that she has recognized that she needs to make a change, but is
unsure about making the change, due to barriers in her life.
2. Calculate her BMI. How would you interpret it? How does her waist circumference
measurement add to your assessment?
BMI: lbs./ inches2 x 703
178 lbs. / (66 in2) x (703) = 28.7, therefore the client is classified as being overweight
based on her BMI of 28.1
The patients waist circumference is 38 inches and the recommendation for females is no
more than 35 inches.1 Therefore, this is another indication that the client is overweight
and it also indicates that the client has one of the five risk factors of suffering from
metabolic syndrome.
3. What does her history of giving birth to heavier than average babies suggest?
Macrosomia is caused when extra glucose from the mother is converted to fat and crosses
the fetal placenta.1 Therefore, the fetuss pancreas responds by releasing extra insulin to
cope with the excess glucose supply from the mother causing the baby to be born heavy.1
Giving birth to babies over 4000g is referred to as macrosomia and the risk of this
occurring increases with women who are obese.1 Based on the clients previous history of
losing and gaining weight before pregnancy, its indicated that the patient was either at a
healthy weight or slightly overweight at the time of her first pregnancy. The current
recommendations for a healthy weight pregnant women are to gain between 25 to 35
pounds, but for an overweight woman, they should only gain between 11 to 20 pounds.1
According to the patients past history, she gained about 40 to 50 pounds at each
pregnancy and never completely lost it all after giving birth. Therefore, due to the
excessive weight gain, the patient was overweight when she was pregnant and as a result
it caused her babies to be born heavier than average babies.
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?

 Yes, the patient displays all three causes of metabolic syndrome such as: being
overweight and physically inactive, and has a genetic predisposition to being overweight.
Therefore, in order to be diagnosed with metabolic syndrome, the patient/client needs to
meet at least three out of five risk factors associated with metabolic syndrome and this
particular patient meets all five. Such as:
o 1) Current waist circumference is 38 inches, which is over the
recommendation of 35 inches or less for women.1
o 2) The patients serum triglyceride level is above 150 mg/dL; it is 189
mg/dL.1
o 3) HDL cholesterol is under 50 mg/dL and should be greater than 50
mg/dL. 1
o 4) Blood pressure is 140/ 90 mm Hg, which is above 130/ 85 mm Hg.1
o 5) Fasting glucose is 126 mg/dL, which is over 110 mg/dL.1
Incorporating a healthier diet can help manage all of the factors associated with metabolic
syndrome. It can help a person lose weight, control his or her serum triglycerides,
increase their HDL cholesterol levels, and maintain both blood pressure and fasting
glucose levels as well.1 To treat metabolic syndrome, some patients need to lose weight
and incorporate healthier eating habits into their lifestyle. However, every treatment is
different, based on how much weight a patient should lose or if a restricted diet needs to
be implemented or not. One recommendation is to lose about 0.5 to 1 pounds per week by
calorie, fat grams and physical activity targets.1 All in all, healthier eating habits can help
develop a healthier weight and can help manage each factor associated with metabolic
syndrome. Another treatment is to incorporate daily exercise. For example, the current
recommendation is to perform at least 60 to 90 minutes a day of physical activity.1 As for
patients who are overweight or obese, they should gradually increase to this level of daily
activity.1 However, thirty minutes a day of moderate intensity has been shown to facilitate
weight control.1 Exercise can help increase your HDL levels, acquire a healthy weight,
and lower a persons risk of falling into the set risk factor levels associated with
metabolic syndrome.
5. What can you do to help her become more motivated from within herself to change her
diet and exercise behaviors?
The goal for a patient/client who is unsure about making a change is to build readiness to
change. This can be achieved by enhancing the self-efficacy in the patient, providing selfmotivational statements, using open ended questions, using reflecting techniques, and
negotiating with the patient.1 For instance, by encouraging the client to explore all pros
and cons about herself can help her become more motivated to make the change. Such as
asking her what she likes or doesnt like about her current eating habits.1 After focusing
on ambivalence, talking about the future after the patient has incorporated healthy eating
and exercise routines can help expose the advantages that can arise from making the
change and also identify the barriers that can prevent the change.1 Another way to
motivate the client is to negotiate with her. This can be started by setting broad and easily
attainable goals.1 After goals have been set, provide strategies to achieve them and
ultimately have her make her own plan of reaching them.1

 Another motivational method that could be used, is to shift focus while counseling this
client. For example, you could address the clients resistance to change due to not having
any time to exercise. Therefore, in this case suggest that time is not the only reason that is
keeping her from exercising, but it may be her own attitude about exercising. It could
possibly be due to her fear of failing to complete an exercise regime or that she does not
want to lose time that she could be spending with her kids. Overall, this method can help
rule out other barriers and help determine which obstacle is the main cause of the
patients reluctance to make the change.
6. Assuming she becomes ready to take action, identify some initial steps that she might
take to improve her diet.
According to the patients diet history, she eats high amounts of fat, sugar, carbohydrates,
low nutrient dense foods, and starchy vegetables. In addition, the patient does not eat
enough protein, whole grains, fruit, or vegetables. Thereby, the patient should start
eliminating her high fat, high sugar dessert snacks by choosing to eat fruit or vegetables
in order to increase her intake of fiber, vitamins and minerals. The patient could also
increase her fiber intake by consuming more whole grains, therefore she can increase her
satiety level and stop over snacking throughout the day. To lose weight she should eat
about 6 oz. of whole grains a day. 2
The client should also restrict her saturated fat intake by reducing her high sugary food
choices to no more than 20 grams a day.2 Reading food labels and watching portion sizes
can help her achieve this goal. However, the client does not have to give up all her
favorite dessert foods, due to the fact that moderation is the key. Instead the client can eat
a cup to 1 cup of frozen yogurt or eat a reduced sugar pack of pudding as a substitute
for other desserts.
According to the patients diet history, she does not eat enough protein a day, instead she
eats high carbohydrates and high fat food items. Consuming a lot of desserts and white
based products will cause her glucose levels to rise and cholesterol levels to rise as well,
which are both shown in her lab values. The client needs to eat about 5 oz. of protein ad
day to lose weight.2 For instance start having a turkey sandwich with spinach on wheat
bread for lunchtime, instead of a white breaded, peanut butter and jelly sandwich. Also
incorporate grilled chicken or fish for dinner alongside of brown rice and broccoli. This
change will help keep her full and provide her body with high amounts of protein, whole
grains, vitamins and minerals that her body needs in order to perform at its greatest
allowance.
The clients sodium and potassium levels are within the recommended ranges, but her
sodium level is getting close to being too high. Therefore, the client should watch her
sodium intake with her food choices such as potatoes, and meat choices.
The client may strive to stop skipping breakfast and stop relying on snacking three times
a day, to fulfill her appetite. She can achieve this by eating three full meals a day and by
incorporating small snacks once or twice a day, to avoid overeating.
The client can start eliminating excess sugar and high fat foods as well. Instead she can
include more nutrient dense foods in order to promote satiety and prevent fluctuations in

her glucose levels. For instance, she can eat more whole grains; such as whole wheat
bread and brown rice. The client should also replace her sugary drink choices such as
soda and fruit juice by drinking more water and making sure that her fruit juice choices
are 100% fruit juice and no sugar is added to them.
The client could also strive to offer healthier snack choices to her kids such as fruits or
vegetables for an after school snack. This could help her eat healthier after school snacks
with her kids and could help set a better example for them as well. However, if the kids
refuse to eat a piece of fruit instead of cookies, she could offer them peanut butter with an
apple and possibly only one cookie, in order to gradually associate them to making
healthier food choices.
The patient could also begin cooking healthier meals for herself and her family.
Therefore, more satiety, nutrition, and energy levels will be achieved.
Use stimulus control methods, by putting utensils down between bites, pausing during
meals, and chewing for a minimum number of times are some ways to slow the eating
process down.1

7. What is the role of physical activity in weight loss and weight maintenance? How does
aerobic activity, strength training, and stretching all contribute to optimal weight
management?
By Increasing LBM (lean body mass) in proportion to fat, physical activity helps to
balance loss of LBM and reduction of RMR (Resting metabolic rate) that accompany
intentional weight reduction.1 Physical activity also strengthens cardiovascular integrity,
increases sensitivity to insulin, and expends additional energy and calories.1 These all aid
in promoting weight loss.
In order to facilitate long term weight control and improve health related outcomes,
certain physical activity routines need to be followed.1 Such as participating in at least 30
minutes of moderate intensity exercises or working out for 60 to 90 minutes on a daily
basis.1
Resistance training increases LBM, adding to the RMR, and the ability to use more of the
energy intake, and it increases bone mineral density, especially in women.1 Aerobic
exercise is important for cardiovascular health through elevated RMR, calorie
expenditure, energy deficit, and loss of fat.1 Stretching helps increase blood flow
throughout the body and increase flexibility as well.1
8. What methods would you suggest she could use for self-monitoring?
The patient should use a food and activity log or use a daily planner.1
A daily record can indicate place and time of when food is eaten.1 Also it can identify
thoughts, feelings, and any problems that might arise when eating.1 Physical activity can
also be recorded with amount of minutes to complete exercise and calories burned
throughout workout.1 A daily record can help address any relapses that the client has gone
through by showing the cause and determining how to prevent it from occurring in the
future.

 The client should keep a journal and write down everything she does within each day of
the week. She should not only include everything she eats, but also include what physical
activity she performed throughout her day. The patient should have comment boxes next
to any event that caused her to have mixed emotions and feelings about reaching her
goals or changes successfully. Overall, each log should be detailed in order to address
barriers or triggers that could affect the patient from achieving her goals.

9. Make suggestions for handling family meals, special occasions and holidays.
To handle family meals, the patient should incorporate healthy meals at a gradual level.
In order to be successful for herself and her family, she needs to make small changes first
in order to avoid failing. Therefore, she could begin the change by cooking healthy meals
but also include several options, such as if one person doesnt like sweet potatoes, have
brown rice made in order to swap out for the sweet potato. This can help eliminate
negativity, but also keep the meal healthy and successful. The client should also write
down everything that occurred during dinner as to how she felt and what foods she didnt
like as well. Therefore, everything can be addressed at a follow up meeting.
Another method to use is to know that moderation is the key. For holidays and special
occasions, food is what brings everyone together and they are not always the healthiest
options. Therefore, the patient should use mindful eating strategies and portion control.
For example, the client does not have to eliminate all unhealthy foods, but needs to keep
in mind how much food they are actually eating. She needs to watch how many scoops of
mashed potatoes she is putting on her plate and identify the size of the piece of pie that
she is eating. Overall, she needs to listen to her body to know when she is full and also
use stimulus control strategies to avoid overeating. Also the client needs to make
comments in her journal about how the experience went and also what barriers she felt
were causing her any relentlessness to avoid overeating within a group setting.
10. Write a PES statement based on her initial presentation. How would you monitor and
evaluate the effect of your interventions?
PES statement: Excessive energy intake related to regular consumption of large portions
of high-fat, high sugar, low nutrient dense meals and snacks as evidenced by diet history,
waist circumference of 38 inches, BMI of 28.7, and meets all risk factors associated with
metabolic syndrome.
Monitor/ Evaluate:
o Monitor patients progress by viewing patients personal daily record in each one
on one session.
o Monitor patients progress of attaining a weight loss goal of .5 to 1 lb. a week.
Incorporate weigh ins once every two weeks.
o Evaluate the success rate of the patients physical activity target of performing at
least thirty minutes of moderate activity on a daily basis.
o Evaluate that patient is consuming less high fat and high sugar foods throughout
the day.

o Monitor that the patient is not falling into old habits and is maintaining to eat 5
oz. of protein, 6 oz. of whole grains, at least 2 cups of vegetables, 1 cups of
fruit, and at least 3 cups of dairy a day.2 Evaluate the clients overall calorie intake
of eating no more than 1800 calories a day.2
o Monitor and evaluate that the client is progressing with her readiness to change.
Evaluate her feelings and ensure that she is incorporating all recommendations
into her daily routine in order to successfully make the change a habit.

Menu2:
Your plan is based on a 1800 Calorie allowance.2

Date
10/21/1
5

Breakfast
cup
Blueberries, raw

1 mug (8 fl
oz)
Coffee,
brewed,
regular

1 tablespoon
Honey

Lunch

Dinner

Snacks

2 regular slice
Bread, 100%
whole wheat

1 cup, cut stalks

Broccoli, fresh,
cooked (no salt or
fat added)

1 small (2-1/2"
across) Apple.
Raw

6 baby carrot(s)
Carrots, raw

1 medium potato
(5" long) Sweet
potato (yam),
baked (no salt
added), peel eaten

3 small stalk (5"

long) Celery, raw

1 container (6 oz)
Greek yogurt,
fruit, fat free

2 fillet Tilapia,
baked or broiled,
without fat

cup Chocolate
pudding, sugar
free dry mix, with
fat free (skim)
milk

8 fl ounce(s)
Skim Milk
1 cup Oatmeal,
regular, cooked
(no salt or fat
added)

3 teaspoon
Mustard

8 fluid ounce(s)
Skim milk

cup Spinach,
raw

1 ounce (14
halves) Walnuts

6 thin slice (3" x

2" x 1/8")
Turkey, white
meat, roasted,
skin not eaten

2 tablespoon
Peanut butter,
reduced sodium
and reduced sugar

Total Calories: 17932

Overall, the client will meet or exceed recommendation levels of grains, dairy, fruits, vegetables,
and protein needs. Also the client will consume water throughout the day and with meals as well
if preferred.2

Empty Calories Limit: 161, eaten 102 2

Limit 5 tsp. oils, eaten 5 tsps.2
Limit: 20g saturated fat, eaten 9 g 2
Limit: 2300mg sodium, eaten 2251mg 2
Cholesterol: <300 mg, eaten 189mg 2
Potassium: 4700 mg, eaten 4794 mg 2
As for all the other vitamins and minerals they will be met within recommended levels as well.2

Reference List
1. Mahan L, Escott-Stump S, Raymond J, Krause M. Krause's Food & The Nutrition Care
Process. St. Louis, Mo.: Elsevier/Saunders; 2012.
2. United States Department of Agriculture. Supertracker Website.
https://www.supertracker.usda.gov/MealSummaryReport.aspx. Assessed September 15, 2015.