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Case Study #3

Ryan Struder
Nutrition Therapy
Professor Elkadi

Case Study #3

1. Describe the stages of readiness for change, and identify where you think she falls on this
continuum. (4 points)

The stages of readiness for change are described by the six stages of change in the
Transtheoretical model (TTM). This model describes behavior change as a
process of progression through the stages of: 1) Precontemplation- Individual
has not thought about making a change. 2) Contemplation- Individual has
thought about making a change, but thats it. 3) Preparation- Individual has taken
some steps to begin change. 4) Action- Individual has made the change and
continues it for less than six months. 5) Maintenance- Individual has continued
the behavior for longer than six months. 6) Termination- Individual no longer
thinks about the change, its now a habit.1 The patient in the current case study
would fall into the Contemplation stage because she is aware that she is
overweight and has attempted a few diets to lose the weight before being referred
to the dietitian. She tells the RD that she wants to be healthier and set good
examples but fails because of lack of time and her kids eating habits. So she
shows that she has thought about changing her behavior but hasnt done any
actual real change besides attempting a few fad diets.

2. Calculate her BMI. How would you interpret it? (2 points) How does her waist
circumference measurement add to your assessment? (2 points)

Her current BMI is 28.7 which puts her into the overweight category. Her current
waist circumference at 38 inches adds to the fact that an increase of waist
circumference has a correlated consequence of an increase in BMI. These are
significant predictors of heart failure and other risks associated with obesity.1,2

Sense she also has too low of a number of HDL cholesterol and too high of a
glucose and triglyceride reading she can be diagnoses with having metabolic
syndrome. She is a risk factor for more than 5 out of the 5 factors.2

3. What does her history of giving birth to heavier than average babies suggest? (5 points)

Based off using her old body weight before birth she was at a BMI of 22.6
putting her into a normal health range. She should only have gained between 2535lbs, however this is not the case since she stated she gained 40-50lbs with each
pregnancy. We dont know weight at birth but if she was overweight at the time
then the recommended amount of weight gain would have been 15-25Ibs
according to the Institute of Medicine (IOM).1 The fetus is able to use excess
subcutaneous fat from the abdomen, back, and upper thigh for energy stores.
There is also evidence that rates of large for gestational age (LGA) newborns tend
to be higher when pregnancy weight gain exceeds that of recommended.
Overweight and obese women are at increased risk of intrauterine fetal demise
(IUFD) or miscarriage, gestational diabetes mellitus (GDM), pregnancy-induced
hypertension (PIH), and cesarean section.1,2

4. Does she meet the criteria for this syndrome according to the National Cholesterol
Education Panels Adult Treatment Panel III? (3 points) How is metabolic syndrome
treated with diet and physical activity? (3 points)

Yes this patient does meet the criteria and should be diagnosed with having
metabolic syndrome. In order to be diagnosed with this condition, the patient must
have at least three of the five risk factors. Those risk factors are: Waist
circumference of >40in in men and 35in in women, Serum triglycerides
150mg/dL, HDL cholesterol <40mg/dL in men and <50 mg/dL in women, Blood
pressure 130/85mm Hg, and fasting glucose 110mg/dL.3 This individual is
currently displaying all five of the risk factors. In order to counteract this
condition healthy eating habits and daily exercise are needed. Exercise will not
only help to increase weight loss and promote an increase in muscle mass and
increase the HDL levels, but it will help to decrease insulin resistance, triglyceride
levels, abdominal circumference and additionally blood pressure. There are also
two other diet recommendations which are The Dietary Approaches to Stop
Hypertension (DASH) diet and the Mediterranean Diet, like many healthy-eating
plans, limit unhealthy fats and emphasize fruits, vegetables, fish and whole grains.
Both of these dietary approaches have been found to offer important health
benefits in addition to weight loss for people who have components of metabolic

5. What can you do to help her become motivated from within herself to change her diet
and exercise behaviors? (5 points)

There are many different ways to approach a counseling session with your patient.
One great strategy to use for this patient would be to use Motivational
interviewing (MI) which encourages clients to identify discrepancies between
how they would like to behave and how they are behaving, and then motivate
them to change.1 By using MI you can express empathy to the client and make a
solid connection to help them see where they will be able to make successful
behavior changes. Another great approach for this client would be to use cognitive
behavior therapy (CBT) which can be used to help individuals develop skills to
achieve healthier eating habits. Instead of helping to decide what to change, it
helps to identify how to change.1

6. Assuming she becomes ready to take action, identify some initial steps that she might
take to improve her diet. (5 points)

Her current diet and meal pattern contains too many empty calories. By changing
her snacking habits from the empty calories in junk food to more nutritious snacks
such as fruits or veggies with low-fat dip or cheese she can lower her fat and
calorie intake.
Eating a balanced breakfast and decreasing the amount of sugary drinks. She
should try to start consuming more water with meals instead of drinking more
sugar and calories.

7. What is the role of physical activity in weight loss and weight maintenance? (3
points) How do aerobic activity, strength training, and stretching all contribute to optimal
weight management? (3 points)

Physical activity will help her to lose weight, raise her HDL levels, and help
balance her glucose levels, decrease her BMI and waist circumference and lower
her blood pressure. Physical activity is extremely important to the health of any
individual. Resistance training increases LBM, adding to RMR and the ability to
use more of the energy intake, and it increases bone mineral density, especially for

women.1,2 Aerobic exercise is important for cardiovascular health through

elevated RMR, calorie expenditure, energy deficit and loss of fat. Stretching
actually helps to promote blood flow and release endorphins for that feel good
sensation and helps with muscle soreness.

8. What methods would you suggest she could use for self-monitoring? (5 points)

One great method for her to use as self-monitoring would be to keep a week log
food and exercise journal. For one week she would write down everything she is
eating or drinking as well as her daily activities. This is a great tool because it
allows the patient to think more consciously about what they are going to eat
sense they will be recording it and to help remind them that they should try to get
some more exercise for the day. After that week she would report back to the RD
to discuss improvements and address any other concerns.

9. Make suggestions for handling family meals, special occasions, and holidays. (5 points)

This patient has made it clear that cooking meals can be a problem because of
what her kids like to eat and she doesnt have the time or effort to cook two
meals. One way to help her would be to have the patient bring in her menu plans
for holyday meals, or everyday dinner ideas. Most people arent aware of the
recipe modifications that there are to produce a very similar meal with much less
sodium, fat, calories, and have higher nutritional values. Also its important to
make sure she understands portion control, and not to engage in mindless eating
habits such as watching TV while continuous eating.1

10. Write a PES statement based on her initial presentation. How would you monitor and
evaluate the effect of your interventions? (5 points)

Excessive energy intake related to high caloric dense foods as evidenced by a

BMI of 28.7 and a waist circumference of 38 inches.1
In order to be able to monitor and evaluate her, I would try to set up her
appointments to at least once a week depending on patient availability. At each
session Id go other her food and exercise journal her with and discuss how she
did and if any goals were met. Its also important to get new blood work and
anthropometric measurements of the patient for each consultation to be able to
compare previous weeks and test for effectiveness of the nutritional plan.

1. Mahan L, Escott-Stump S, Raymond J, Krause M. Krause's Food & The Nutrition Care
Process. St. Louis, Mo.: Elsevier/Saunders; 2012.
2. Nelms M. Nutrition Therapy And Pathophysiology. Australia: Wadsworth/Thomson;
3. Emery E. Clinical Case Studies For The Nutrition Care Process. Burlington, MA: Jones
& Bartlett Learning; 2012.