Obesity Fitness Plan for Marsha

By: Danielle Petit

Marsha is a 51 year-old female case study on page 310 of the Howley and
Franks text, Fitness Professional Handbook. She came into the fitness center
interested in information on buying a gym membership. She showed special
interest in the weight loss program because she is 5 feet 5 inches tall and weighs
240lbs. She is showing cardiac side effects as evidenced by a blood pressure
reading of 152/88. She lives a sedentary lifestyle because she shows no plans for
leisure activities and has a desk job. She shows lack of wellness awareness as
evidenced by her lack of a yearly physical. Her last medical exam was three years
ago. There is presence of cardiac disease on her fathers side of the family and her
mother has type II diabetes which was diagnosed after menopause.

PAR-Q Rating
We would want to do a PAR-Q on this person to better identify any risks that would
cause concern and need for physician approval prior to exercise. The PAR-Q is a
health assessment to evaluate the persons physical activity readiness. It asks the
following questions: Has your doctor ever said that you have a heart condition and
that you should only do physical activity recommended by a doctor? Do you feel
pain in your chest when you do physical activity? In the past month, have you had
chest pain when you were not doing physical activity? Do you lose your balance
because of dizziness or do you ever lose consciousness? Do you have a bone or
joint problem (for example, back, knee, or hip) that could be made worse by a
change in your physical activity? Is your doctor currently prescribing drugs (for
example, water pills) for your blood pressure or heart condition? Do you know of
any other reason why you should not do physical activity? (Thygerson&Thygerson,
p.243). If the client answers yes to any of these questions they should seek medical
advice prior to planning an exercise plan.
Health

Status

The HSQ or Health Status Questionnaire is a more thorough health status

exam. The questions are more involved and help the fitness professional identify
areas of concern or special precautions that may need to be put in to place for the
individual based on their health status. There is a health status questionnaire in our
Fitness Professionals Handbook (form 3.2 on pg. 26). In part 1 we will gather
personal information especially a contact person to call in case of an emergency.
Her height and weight is recorded here as well (55, 240lbs).
Part 2 deals with her general medical history such as heart health history,
symptoms experienced upon exertion or additional health issues. If she had
concerns with conditions such as asthma, diabetes, joint problems, cramping,
pregnancy or medications they may be taking we may decide to get a physicians
approval prior to making a plan. Remember she hasnt had a physical in three

years, but by asking questions about these matters the professional can make a
judgment on the importance of getting that approval.
Part 3 deals with risk factors such as age, activity level, blood pressure, and
cholesterol and waist circumference. This is where we would inquire more
information about her fathers cardiac history and put information about her blood
pressure because she was borderline having a high systolic reading. If her father
had a heart attack, surgery or death related to cardiac causes prior to age 55 it
would be wise to have a cardiac assessment performed by a doctor.
Part 4 would include a list of current prescribed or over the counter
medications. Being that she hasnt been to the doctors for a medical assessment
doesnt mean she hasnt obtained medications through sick visits or isnt taking
OTCs to treat symptoms. This is a good way to identify problems that may not
otherwise come up. For example, she may say she doesnt have any joint problems
but may report she takes Advil every day to treat back or knee pain.
Part 5 assesses physical activity patterns and objectives. It appears by her
report of having a desk job and no leisure activity plans that she live a sedentary
lifestyle. We would question her specific goals. This is a good time to make short
term behavioral change goals as well as weight loss goals. She would benefit from
answering some questions regarding her current view on physical activity and her
nutritional intake. Weight loss success heavily weighs on readiness to make lifestyle
changes. Her current physical activity type, frequency and intensity would also be
addressed and discussed here.
General

Medical History

This case study gave very straight forward information but fell short on giving
some required information to complete some of these assessments. Lets assume
that the only areas of concern are her family history of Type II diabetes, which more
than likely means obesity runs in her family, and the fact that her father had cardiac
disease. She has two risk factors that we are unable to identify the severity of. Her
mother having Type II diabetes after menopause puts her at risk for diabetes. Being
that the woman is 51 years old and around the age of menopause we should
probably do some fasting blood sugar tests if we have access to a glucometer or a
professional available that is qualified to do so. It would be a good idea to educate
her on the effect of exercise on blood sugar. If she knows exercise drops the blood
sugar and causes dizziness, disorientation, fatigue, nausea, and irritability she will
know when to report feeling these symptoms and it will make assessment easier.
Otherwise, she should be sent to a doctor for a physical. We also would want to
evaluate any symptoms she reported during the PAR-Q or HSQ especially related to
cardiac.

Assessments
For assessments I would calculate her BMI or body mass index. According to
the BMI calculator on www.exrx.net, Marsha has a BMI of 47, which puts her in level
3 obesity or better known as morbid obesity. Finding out her body composition
would be helpful as well. If more information was supplied we would be able to
better define her body composition in terms of fat distribution and what areas need
to be focused on the most. Questions related to Marshas insecure areas would
be asked as well.
An assessment of Marshas daily caloric need was made. She needs to
consume 2,453 calories a day to maintain her current weight. If Marsha was serious
about her attempt at weight loss I would consider how overweight she is as a big
picture. Lifestyle changes will be difficult for a person this large because their
bodies are so used to high fat diets. A negative caloric balance needs to be
achieved to lose weight. If she were to start slow by decreasing her daily caloric
intake to 1,879 calories she would be more likely to maintain the decrease in her
diet but would be at a minimal weight loss recommendation of 0.5lbs a week.
Assess areas that need change. For example, behavioral and lifestyle
changes which are needed for ultimate success with losing weight and keeping then
keeping it off. Marsha should limit her intake of fat to less than 30% of her diet.
The fat she does consume should come from healthy fats such as avocados or nuts.
The behavioral changes will come with stopping her urge to grab a bagel with
cream cheese for a mid-morning snack and instead having some trail mix with
cashews. Her sedentary lifestyle would need to be addressed and alternative
measures discussed.
Risk

Factors and Precautions

Marsha is at risk for diabetes type II and cardiac related to her lifestyle and
familial history. She does show interest in changing her lifestyle but lets assume
her diet is poor as well as her activity level. Again, Marsha is 51 and if not in
menopause then she soon will be. Her mother developed Type II diabetes and was
more than likely overweight as well because Type II diabetes is primarily diagnosed
in correlation with weight opposed to age (like Type I).

Medications
No medications were listed in the case study. This section would be used to
review what meds shes on and what side effects they have on exercise. By
reviewing the meds, their effectively and possible side effects that could put Marsha
at risk for injury we can assess red flags while carrying out her fitness plan. For
example, if she was on cardiac medication to lower her blood pressure and a listed
side effect was syncope with exertion, we would adjust the intensity of her work out

to low-moderate depending on her physical reaction to the activity. Knowing which

meds have which side effects makes safety during exercise safer for Marsha.

Health and Lifestyle Behaviors

Marshas case study describes her lifestyle as sedentary. The case study
doesnt say much about her behaviors. We would evaluate different behaviors that
may become a barrier to her change in nutritional intake and commitment to
physical activity. Here we may want to discuss what makes her want to eat besides
hunger and ways to choose better snacks or how to avoid eating at those times.
Planning meals ahead of time or cooking and freezing meals helps to have healthier
choices readily available and decreases risk of make poor nutritional decisions
related to time constraints.
We would discuss her social life and determine a strong source of social
support to help her remain motivated and determined.

Body Composition
Body composition would be evaluated but we are missing measurements to
appropriately calculate her body composition. Knowing measurement about her
girth or hip to waist ratio would give more information regarding which areas need
the most work. Being that her BMI reads morbidly obese and the fact that shes
only 55 makes me think she has an apple figure; short and round. Strengthening
exercises would be helpful and resistance exercises.

Nutrition
No information was given regarding her nutrition. We will go with statistics
from our Fitness Professionals Handbook and assume that because she is
overweight (significantly) that her diet consists of simple carbs (which provide a fast
boost in energy or blood sugar but dont provide substantial nutrition) and high fat
content. We would go over recommended daily allowances of all food groups and
express that fat consumption should be less than 30% of her daily food intake and
should come from healthy sources.
We would go over the recommended daily values and discuss some ideas on
how to meet her daily nutritional needs. The food pyramid always seems to help
because most people are familiar with it and find it easy to follow. We would discuss
her dietary likes and dislikes at this point to try to determine where she needs to
change her behaviors in relation to her diet and give compliments to existing good
eating habits.
www.exrx.net gives some of the following recommendations to help control
poor dieting: eat smaller meals throughout the day, eat a snack during the time

you are without food the longest during the day, plan 3 meals and 2 or 3 snacks
distributed throughout the day (to avoid breakthrough hunger), prepare extra
when cooking meals so leftovers are available for future meals verses fast food,
decrease portion sizes of your largest meals, eat more fiber (substitute 100% whole
wheat for white bread), add beans or vegetables to meals (if you find it hard to eat
vegetables or fruit try veggie juice or fruit smoothies), buy pre-cut veggies and
salad mixes for convenience, eat 5 servings of fruits and vegetables every day and
keep a list of servings eaten , choose lower fat condiments, choose dairy products
with lower fat (2%, 1%, 1/2%, Skim or non-fat). The website offers the following
ideas for better appetite control: eat a snack before lunch or dinner to reduce the
tendency to overeat, keep a food journal, try to rate your appetite after each time
you eat: 1) Very Hungry, 2) Hungry, 3) Satisfied, 4) Full, 5) Very Full [eat until you
feel comfortable (rating of 3), leave food on plate, limit eating at restaurants, eat
before being around processed snack foods (parties, work meetings, etc).

Readiness for Change

Marshas readiness for change will be evaluated. Being that she came in to
the fitness center looking for information makes me think she is in the
contemplative stage. To better determine which stage she is in and specifically
identify areas that need to be changed as far behaviors or lifestyles I would utilize
some of the questionnaires supplied in our Fit to be well lab section. This would
require interaction with Marsha because there are personalized questions that need
to be answered which cannot be completed with the limited information supplied in
the case study. Again, being that she is inquiring about weight loss programs shows
she recognizes a problem and is being proactive about it she should be
complimented.

Motivational Strategies and Techniques

Reinforcing her self-esteem and self-efficacy as often as possible will increase
the likelihood of her following through and moving up the fitness ladder to wellness.
By pointing out positive behaviors Marsha displays now would help her remain
confident and increase her self-esteem further reinforcing her interest in exercise
and weight loss. I would express to Marsha how important it is to view her fitness
plan as a change in lifestyle and not a temporary diet to lose weight. She will be
more successful in maintaining her weight loss goal if she changes her bad habits
permanently.
I think small steps are better with people who are obese. Slowly cutting back
her daily caloric intake will allow her body and mind to slowly adjust to the changes.
Starting with less aggressive aerobic exercise in shorter bouts (10 minutes of
moderate intensity activity 3 times a day) would be more effective or likely to be
tolerable. Not only will she start to feel better but she will start to see small

increments of weight loss that may encourage her to do more. It is helpful if the
client is competitive with herself.
Either adding therapy or support groups are great ways to encourage her to
do her daily routine. She would have access to other people who struggle with
obesity and would be able to compare symptoms and results of her activity if she
were to join a group therapy. A personal therapist would be good to decrease
anxiety and depression. A therapist would also make it more likely that her needed
lifestyle changes would occur. Marsha would be able to privately express habits and
feelings correlated with those habits making it more likely that she would be able to
change them.
I also think it is important to discuss reality. Shows on TV like The Biggest
Loser set weight loss goals that are unrealistic for the average Joe. It becomes
dangerous when weight loss goals are set too high without medical professionals
overseeing the activity. It should be pointed out that she will take longer but is able
to get the same results through repetition, motivation, ambition and determination.
It should also be pointed out that she will have her goals set lower to be able to
evaluate her success and do so safely as to not put her at risk for respiratory or
cardiac side effects. Marsha can change and increase her goals as her endurance
increases.

Recommendations
There are many weight loss medications available. I would educate her on
the fact that changing lifestyle habits (especially diet and exercise) are the most
effective and that many of the weight loss products come with side effects or work
short term. The best way to lose weight and keep it off is to eat healthy and
increase physical activity over a long period of time.
Being that she is morbidly obese and hasnt had a medical work up in three
years, I would suggest she go see a doctor prior to starting her fitness plan. As
discussed earlier, I think she would benefit from starting slow to avoid becoming
discouraged or experiencing uncomfortable symptoms that may prevent her from
continuing. The heavier someone is the more energy it takes for them to move. If
we started Marsha out at the normal recommended physical activity of 150 minutes
of moderate intensity exercise a week she may become exhausted quickly and give
up on the plan before she saw any results. On the other hand if we encouraged her
to meet the goal of lb of weight loss a week she would see results but also start
her physical activity at a realistic level that she would feel physically comfortable
doing while building tolerance and endurance.
As recommended by the ACSM obese adults should exercise on most if not all
days of the week. They should be meeting a minimum of 150minutes a week. I
would recommend starting as slow as we need to in order to build endurance and

make it a short term goal to meet exercise requirements as follows: 5-7 days a week
of moderate intensity physical activity. She should be doing short increments of
exercise at first (whatever she is comfortable with) and increase to 45 to 60 minutes
a day. It is recommended that aerobic exercise be combined with resistance
exercise to obtain the best fitness outcome.
Overall, I think an evaluation of her knowledge of fitness and exercise would
benefit her plan. This way any misunderstandings can be addressed and she can be
educated on healthy practices. Encouragement and setting realistic goals are
supper important to her plan. It is important that she reward herself and feel
satisfaction when benchmarks are reached and her goals should always be
evaluated and updated as her endurance, interest, and motivation increase.

References:
Thygerson, Alton L. Thygerson, Steven M.(2011).Fit to be Well Textbook.Sudbuy, MA:
Jones&BartlettLearning,LLC.
Howley, E., Franks, B.D.(2007).Fitness Professionals Handbook(5th ed).Champaign,
IL: Human Kinetics.
http://www.exrx.net/Calculators/BMI.html
http://www.livestrong.com/thedailyplate/