Case Study #3

Brooke Zaner (N00864405)

Medical Nutrition Therapy I
Instructor: Michelle Elkadi
10/26/2015

1.

Describe the stages of readiness for change, and identify where you think she
falls on this continuum.
The transtheoretical model o(r stages of change model) consists of a series of six
stages to assess readiness for client change. The stages are as follows:
Precontemplation (not ready) - The individual does not intend to take action in the
foreseeable future.1
Contemplation (getting ready) The individual is thinking of changing; they are
weighing the pros and cons.1
Preparation (ready) - The individual intends to take action to change in the
immediate future, usually measured as within a month. They may take a health
education class, speak with a counselor, or their physician to discuss and prepare for
the change.1
Action The individual has made specific overt modifications in their lifestyle and
has measureable change over a six-month period.1
Maintenance The individual has made modifications in their lifestyles and are
working to prevent relapse; however, they do not apply change processes as
frequently as within the Action stage. Researchers have estimated that Maintenance
lasts from six months to about five years.1
Termination The individual has is not tempted; they have 100% self-efficacy.1
According to this model for change, I would identify the client as being within the
Contemplation stage. She states "I want to set a good example for my children, but I
am too busy to exercise. The kids wont eat anything but junk and I dont want to
make separate dinners2." This shows that she has thought about changing but has not
done anything to move forward. It is easier for her to point out the cons right now so
she is showing some resistance with excuses.

2. Calculate her BMI. How would you interpret it? How does her waist
circumference measurement add to your assessment?
BMI= wt/ht/ht * 7033
BMI= 178/66/66 * 703 = 28.7

Based on her BMI she is considered overweight. Waist circumference is used with other
factors to determine risk for disease. A measurement of greater than 35 inches in women
is an independent risk factor for disease4. Based on the pt waist circumference of 38
inches she is at risk. A high waist circumference in patients with a BMI in a range
between 25 and 34.9 kg/m2 puts them at risk for type 2 diabetes, dyslipidemia,
hypertension, and CVD.4
3. What does her history of giving birth to heavier than average babies suggest?
If she was not overweight at her pre-pregnancy weight (normal BMI of 18.5 to 24.9) she
should have only gained 25-35lbs.3 If her pre-pregnancy weight was classified as
overweight (BMI 25 to 29.9) she should have only gained 15 to 25 lb.3 She reported
gaining 40-50lbs with each pregnancy without losing the weight after the birth of her
children. One child was born weighing 8lbs 13oz and the other was 9lbs. LGA (large for
gestational age) is a term used to describe babies who are born weighing more than the
usual amount for the number of weeks of pregnancy; LGA babies have birth weights
greater than the 90th percentile for their gestational age.5 The risk of having an LGA baby
increases by approximately 60% compared with normal-weight women; genetics do play
a part.6 Birth weight may be related to the amount of a mother's weight gain in pregnancy;
excessive weight gain can translate to increased fetal weight.5 Metabolic syndrome has
also been shown to be an independent predictor of macrosomia in women5 so this could
be an issue. Gestational diabetes is a very common disease related to LGA babies and
sometimes excess weight gain in the mother is related to this. Most women who have
gestational diabetes during pregnancy develop type 2 diabetes in later years after birth.6
All women receiving proper prenatal care should be screened for gestational diabetes
during their pregnancy, so this is usually caught about half way through pregnancy and
closely monitored. If this had been an issue for her it would have probably been
addressed.
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?
The National Cholesterol Education Panels Adult Treatment Panel III states the patient
must have three of the five risk factors to be diagnosed with metabolic syndrome. The

patient displays waist circumference >35 inches, serum triglycerides >150 mg/dL, HDL
cholesterol <50 mg/dL, blood pressure >130/>85 mm Hg, and a fasting glucose of >110
mg/dL.2 She has all five risk factors and is diagnosed with metabolic syndrome. The
following are dietary changes to follow according to The National Cholesterol Education
Program:7
Factor

Recommendation

Total Fat

25-35%

Saturated
Trans-fatty acids
Polyunsaturated
Monounsaturated
Cholesterol
Total Carbohydrate

<7%
Limit
Up to 10%
Up to 20%
<200 mg/day
50-60%

Fiber
Complex carbs
Refined carbs and sugar
Total Protein

20-30 gm/day
Naturally high in fiber
Limit and individualize
15% (approximately)
Low saturated fat
Limit or avoid
If used, include in total daily caloric intake as 7
kcal/gm
100% of daily calories to achieve weight loss
or maintain acceptable BMI
48-64 ounces daily
+64 ounces with exercise
+64 ounces with sepsis
3 meals
Nutrient dense snacks in between
Daily physical activity with moderate exercise
of at least 200 kcal/day
Within BMI of 18.5 25
Follow guidelines for weight loss
Cessation
May require specialty training for optimal
utilization

Alcohol
Total Caloric Intake
Water Intake
Meal pattern
Exercise
Total Body Weight
Smoking
Stress Management

30-60 minutes of aerobic exercise three to five times each week, anaerobic exercise three
times per week, and daily stretching should be conducted to reach the daily physical
activity recommendations.7

5. What can you do to help her become motivated from within herself to change her
diet and exercise behaviors?
To determine the proper principle to utilize to counsel the patient, motivational
interviewing should be used. Developing discrepancy may be used to help the patient
realize the importance of changing her behavior. Making a list with the patient of pros
and cons, her goals, and what may stand in the way will be helpful. The counselor would
need to roll with the patients resistance if she displays any. She may feel that it will be
very hard to please her children with health foods. Showing the patient recipes that are
healthy, simple, and kid-friendly can promote self-efficacy. The patient needs to feel
motivated to want to begin to try to make changes. Suggesting that she walk with her
children for 30 minutes after dinner can be the start of fun, family friendly exercise
activity. Turning the walk into a treasure hunt for the children can get the whole family
moving.
6. Assuming she becomes ready to take action, identify some initial steps that she
might take to improve her diet.
The patient needs to be part of this process. If she feels like she is not allowed to have a
certain food she is going to want it more, so having her participate in small steps, like
making coffee at home in the morning to monitor the amount of sugar that goes into it,
will make her feel more motivated and that it is less of a burden. She does not normally
eat breakfast, so coming to an agreement on some small type of meal (along with her
coffee at home), can be a huge step. The counselor should explain that breakfast
jumpstarts the metabolism for the day, and encourage her to eat something small, but
nutrient dense. It would be wise to counsel her on pleasing her sweet tooth with a piece
of fruit in place of her midmorning snack where she likes to have a doughnut. Having the
patient commit to having an apple with peanut butter three times a week at first, in place
of the doughnut, will encourage small but long term changes. Switching her bread to
whole grain will be beneficial if she prefers to eat a sandwich for lunch. Based on
Mifflin St Jeor she needs about 1,450 calories a day. Keeping her fats down, and fiber
and protein up, here is a sample meal plan, made in SuperTracker.usda.gov for one day,
totaling to 1,420 calories:

Date

10/26/15

Breakfast

Lunch

Dinner

1 pat (teaspoon) Butter,

stick, unsalted

cup, chopped Carrots,

raw

1 cup Barley, cooked (no

salt or fat added)

1 muffin English muffin,

whole wheat, 100%

cup Chickpeas (garbanzo cup, flowerets Broccoli,

beans), canned (no fat
fresh, cooked (no salt or fa
added)
added)

1 tablespoon Jam,
preserves, all flavors

1 cup, shredded or
chopped Lettuce, mixed
(mixed greens, salad mix,
spring mix), raw

medium breast Chicken

breast, boneless, skinless,
baked

1 cup Skim milk

tablespoon Oil, olive

cup Spaghetti sauce

(marinara), meatless

cup, whole Strawberries,

raw

cup Quinoa, cooked

medium fillet Salmon,

baked or broiled, without fat

1 tablespoon Vinegar,
balsamic

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?
Consistent physical activity increases lean body mass in proportion to fat.3 It also
helps balance the loss of lean body mass (LBM) and reduced resting metabolic rate
(RMR) that accompanies intentional weight loss.3 Physical activity equal to at least 200
kcals per day is recommended by The National Cholesterol Education Panels Adult
Treatment Panel III.7 This can be met with 30-60 minutes of aerobic exercise three to
five times a week (important for cardiovascular health through elevated RMR, calorie
expenditure, energy deficit and loss of fat.3,7 Anaerobic exercise (strength training) three

times per week helps increase LBM, increase RMR, and increases the ability to utilize
energy taken in.3,7 Stretching before and after workouts of any type prevent injury and
promote flexibility, and can reduce stress. Physical activity has been proven to assist in
weight loss and weight maintenance, reduce high blood pressure, reduce risk for risk for
type 2 diabetes, heart attack, stroke, and several forms of cancer, reduce arthritis pain and
associated disability, reduce risk for osteoporosis and falls, and to reduce symptoms of
depression and anxiety.8
8. What methods would you suggest she could use for self-monitoring?
The patient could utilize a food and activity log by creating a daily planner, or, if
applicable, an app on her Smartphone. Myfitnesspal and Super Tracker are great sources
to keep her accountable and knowledgeable about her food choices and exercise activity.
They are helpful for the patient because they can see exactly what choices they have
made and how it affects that day. If she eats a doughnut it will show her how that
affected her caloric intake and other nutrient needs, and she will feel more accountable
for her choices. Bi-weekly weigh-ins with the counselor would be beneficial to monitor
progress. An activity log can be helpful to meet her weekly requirement for physical
activity. This log can be helpful so that there is no under or over estimation. If she can
dedicate 30 minutes per day to exercise, even if that means on some days waking up 30
minutes before her children do, she will see results. Planning out these workout times
and committing to them, even a walk after dinner with the children twice a week, are a
way to get her moving and keep her focused. A meal plan with choices would be
extremely helpful for this patient. Positive progress will be rewarded with feeling
motivated, clothes beginning to fit her better, and feeling less fatigued. These will all
play into motivational factors to help her not relapse. Keeping daily logs lets the patient
look back to see what she did over the past week; this can help her choose better options
for the future.3
9. Make suggestions for handling family meals, special occasions, and holidays.
Weekly meal planning for the family will be very beneficial. Going to the grocery store
with a list is helpful to avoid impulse buys. Planning ahead some crock-pot dinners helps
with busy schedules, and there are many available healthy recipes out there. Being that
the patient has children, she should have snacks available to please their taste but are low

fat, low-sugar, low salt. When choosing cereals for the family, look for whole grains, and
if the cereal is not sweet enough to the palette, try adding some fresh berries to it. Low
and no fat yogurt with granola and fruit is fun for the children to put together themselves
and a health eating choice. Making smoothies for breakfast can be a fun and healthy way
to interact and get the children involved, as well. Keeping snacks on hand like almonds,
chickpeas, and whole grain crackers and peanut butter help lessen the decision making
factor when opening the pantry. Also, prepping some pre-cut vegetables and putting in
small plastic baggies per portion size are a great way to grab and go. Even when children
open the refrigerator and see little baggies of cut up carrots, celery, and peppers, it is
exciting for them to grab a bag and start snacking! Slowly replacing refined white bread
with whole grain options is important. When cooking, flavor foods with herbs, spices,
and low-sodium seasonings. When attending special occasions or holidays, remember
that moderation is key. There is no need to deprive, however, try to make the healthiest
choices, and when indulging, remember portion control and the goal at hand.
9. Write a PES statement based on her initial presentation. How would you monitor
and evaluate the effect of your interventions?
Excessive energy intake related to caloric intake > caloric expenditure, as evidenced by
elevated BMI of 28.7 and waist circumference of 38 inches. Evaluate effect of
interventions by observing decrease in waist circumference and decrease in weight.
Review food and activity logs bi weekly at weigh-ins to assess compliance with the
action plan.

References
1. The Transtheoretical Model. Pro Change Behavior Systems Inc.
website. http://www.prochange.com/transtheoretical-model-ofbehavior-change
Updated 2014. Accessed October 26, 2015.
2. Emery E. Clinical Case Studies for the Nutrition Care Process. Pennsylvania:
Jones & Bartlett Learning; 2012
3. Mahan L, Escott-Stump S, Raymond J. Krauses Food and the Nutrition Care
Process. 13 ed. Missouri. 2012.

4. Guidelines on Overweight and Obesity. The Clinical Guidelines on the

Identification, Evaluation, and Treatment of Overweight and Obesity in Adults:
The Evidence Report. National Heart, Lung, and Blood Institute website.
http://www.nhlbi.nih.gov/health-pro/guidelines/current/obesityguidelines/e_textbook/txgd/4142.htm Accessed October 26, 2015.
5. Large for Gestational Age (LGA). Large for gestational age (LGA). Lucile
Packard Children's Hospital at Stanford website.
http://www.stanfordchildrens.org/en/topic/default?id=large-for-gestational-agelga-90-P02383 Updated 2015. Accessed October 26, 2015.
6. Brown J. Nutrition Through the Life Cycle. Thomson Wadsworth Publishing.
Belmont, CA. 2014.
7. TheThirdReportoftheExpertPanelonDetection,Evaluation,andTreatment
ofHighBloodCholesterolinAdults.NationalHeart,Lung,andBlood
Institutewebsite.
http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/Circulation-2002-ATP-IIIFinal-Report-PDF-3143.pdf Accessed October 26, 2015.
8. Physical Activity for a Healthy Weight. Centers for Disease Control and
Prevention website. http://www.cdc.gov/healthyweight/physical_activity/
Updated May 15, 2015. Accessed October 26, 2015.