Baranowski, 2 Section 1: Readiness for change Transtheoretical model/ stages of change continuum o Precontemplation o recognition for need to change!

e! no intention to take action within the ne"t # months$2 o %ontemplation Recognition of need to change! intends to take action within ne"t # months$2 o Preparation& 'ntends to take action in the ne"t () da*s and has taken +eha,ioral steps in that direction$2 o -ction .as made changes in target +eha,ior for less than # months$2 o /aintenance .as changed target +eha,ior for more than # months$2 Readiness for change: Patient is a 01 *ear old mother of two teenage children$ She comes toda* as a weight loss referral from her primar* care ph*sician 1P%P2$ Patient states, 3' want to set a good e"ample for m* children, +ut ' am too +us* to e"ercise$ The kids won4t eat an*thing +ut 5unk and ' don4t want to make separate dinners$16 -ccording to the transtheoretical model, also called the stages of change counseling approach, the patient is said to +e in the contemplation phase when he or she recogni7es the need to change and intends to take action within the ne"t # months2$ 't appears the patient would like to change, +ut might not *et +e read* to take action$ .owe,er, the fact that she followed up toda* with the referral +* her P%P indicates she ma* ha,e intention to change within the ne"t # months$ B* stating her percei,ed +arriers to change, the patient seems to +e looking for wa*s to take action$

Baranowski, ( 8uestion 2: -nthropometric /easurements Bod* /ass 'nde" 1B/'2 calculation( o B/' 9 1weight 1kg2 / :height 1m2;22 o .eight: ##6 < 2$=0cm/in 9 1#>$#0cm 9 1$#?m o @eight: 1>?l+s < )$0=0 kg/l+ 9 ?)$?1kg o B/' 9 ?)$?1kg / 11$#>m22 9 2?$#(kg/m2 o @aist circumference: (?6 o AAR 9 (=0&1#$B<-2CP-11B$(#< @2 C 1>2# < .22 .eight in meters, weight in kg, age in *ears 9 (=0& 1#$B < 012C1$)11B$(# < ?)$?12C1>2# < 1$#?29 2)0>kcal

The definition of o,erweight is B/' D 2=kg/m2 and o+esit* is D () kg/m2$ The patient has a B/' that falls within the defined range of o,erweight1$ E,erweight/o+esit*, ph*sical inacti,it*, and genetic predisposition are underl*ing causes of meta+olic s*ndrome, and a waist circumference of F (=6 in women is one of the fi,e defining risk factors for the diagnosis of meta+olic s*ndrome 1/etS2$ -lthough +eing o,erweight onl* presents an increased risk of diseases associated with /etS, a waist circumference of F(=6 for females or F0)6 for males presents a high risk of diseases associated with meta+olic s*ndrome$( Since the patient has high B/'/ is o,erweight, and since the patient has the added factor of a waist circumference of F (=6, it can +e determined ma* potentiall* ha,e, or +e at risk for, /etS$ Gurther assessment of TH, .IJ, BP, and fasting glucose are needed to complete a positi,e diagnosis$

Baranowski, 0

8uestion (: %lient .istor* 't is generall* acknowledged that higher +irth weight +a+ies are an indicator of dia+etes in the mother later on, +ut the Pune %hildren4s Stud*0 found that gi,ing +irth to large +a+ies is also an indicator of /etS when looked at eight *ears after deli,er*$ Since the client ga,e +irth to two hea,ier than a,erage +a+ies, and since those children are now in their teens, it would make sense that the client meets criteria for /etS$ 8uestion 0: /etS %riteria and Treatment The ational %holesterol Aducation Panel4s -dult Treatment Panel ''' states that an indi,idual has /etS when he or she meets at least three out of the fi,e following criteria1: o @aist circumference of D0)6 in men and D(=6 in women o Serum THs of D1=)mg/dJ o .IJ K0)mg/dJ in men and K=)mg/dJ in women o BP D1(=/?= mm.g o Gasting glucose D11)mg/dJ The client does meet the criteria for /etS as e,idenced +* her waist circumference of (?6, serum THs 1?Bmg/dJ, .IJ cholesterol of (?mg/dJ, 10)/B)mm.g, and fasting glucose of 12#mg/dJ$ The client meets or e"ceeds all fi,e criteria for risk factors of /etS$

Baranowski, = /etS is treated with diet and ph*sical acti,it* in order to reduce +od* weight, waist circumference, +lood pressure, fasting glucose, and to raise .IJ$ A"ercise is known to positi,el* impact these parameters to a small degree, +ut a low calorie diet 1J%I2 of =))&1)))kcal dail* reduction in intake has e,en a greater effect$ The reduced intake correlates to L&1 pound weight loss per week, and e,en a 1)M loss in weight is correlated with significant health +enefits$ 8uestion =: /oti,ation - moti,ational inter,iewing 1/'2 techniNue2 utili7es four guiding principles: e"pression of empath*, de,elopment of discrepanc*, rolling with resistance, and supporting self&efficac*$ These principles are achie,ed +* e"pressing acceptance and moti,ation, eliciting and selecti,el* reinforcing the client4s own self& moti,ational statements, monitoring the client4s degree of readiness, and affirming the client4s freedom of choice and self&direction$ There are certain implementation techniNues that are useful with this method, such as asking open& ended Nuestions, listening reflecti,el*, summari7ing, affirming, eliciting 3change talk6, and negotiating a change plan$ This techniNue would +e most efficient at moti,ating the client from within herself to change her diet and e"ercise +eha,iors$ 8uestion #: 'nitial Steps -ssuming the client +ecomes read* to take action, some initial step would +e helpful to impro,e her diet: o Reduce current caloric intake +* 1)))kcal a da*, while still maintaining 2/( IR' recommendations for nutritional adeNuac*$ %lient4s AAR are

Baranowski, # 2)0>, so a diet of appro"imatel* 1,=))kcal would still +e a reduction of =))kcal per da* +elow her energ* needs$ Since the client has presuma+l* adapted somewhat to a higher caloric intake, a high initial weight loss is e"pected which ma* impro,e self&efficac*$ o /ake a ha+it of eating +reakfast for long term weight loss$ o -dd fruits, ,egeta+les, and fluids to her diet to reduce caloric densit*, while also reducing fats and including more water content in her foods$ o Su+stitute low fat, low sugar, and low sodium alternati,es where possi+le o -ttend familial counseling to +uild support from famil*$ o Re,iew I-S. diet guidelines for +lood pressure reduction$ o Beginning a regular ph*sical acti,it* 1P-2 program that ma* include walking 1=&() minutes per da*, group dance classes, or increased famil* ph*sical acti,it*$

8uestion >: Ph*sical -cti,it*( @hile P- is the most ,aria+le portion of an indi,idual4s energ* e"penditure, is still counts for appro"imatel* 1=&2=M of an indi,idual4s energ* reNuirements$ Therefore, it pla*s a significant role in weight loss and maintenance, e,en though +asal energ* e"penditure pla*s a much +igger role$ .owe,er +asal energ* e"penditure can +e increased +* e"ercise, since e"ercise +uilds meta+olicall* acti,e lean mass$ -n indi,idual4s le,el of ph*sical acti,it* is correlated to a ph*sical acti,it* 1P-2 coefficient, depending on whether the person is sedentar*, low acti,e, acti,e, or ,er* acti,e that is used in calculating estimated energ*

Baranowski, > reNuirements 1AARs2$ Gor an indi,idual wanting to lose weight, it is recommended the* reduce caloric intake +* =))&1)))kcal of regular AAR, plus increase ph*sical acti,it* from the recommended 1=) min/week to ())min/week for moderate aero+ic acti,it* and >= min/week for ,igorous aero+ic acti,it*$ Besides +uilding lean mass for weight loss, e"ercise impro,es gl*cemic control and impro,es coping and stress management skills which ma* indirectl* increase an indi,idual4s self&efficac* to get healthier$ Together with this client, a goal of 1=) minutes of moderate e"ercise per week within # months should +e set$ The RI should discuss walking or light weight lifting after dropping the children off at school or perhaps taking up a group dance class or famil* acti,it*$ 8uestion ?: Self&/onitoring /ethods2 Self monitoring in,ol,es keeping track of an*thing that influences an indi,idual4s diet and/or weight$ These might include: o @hat is eaten, when, and how much$ Re,iew ,arious food 5ournal t*pes and free popular mo+ile phone health tracking applications with patient$ o -cti,ities during eating$ Iiscuss mindfulness during eating$ o Amotions related to eating$ Iiscuss hunger cues and emotional eating triggers$ o GreNuenc* and duration of e"ercise$ Jog e"ercise using health tracking methods discussed a+o,e$ o utrient content of foods$ Re,iew la+el&reading and nutrient densit* concept$ o egati,e self&talk and replacement thoughts$

Baranowski, ? o /onitoring +lood glucose and +lood pressure le,els$ Ancourage a client to purchase a +lood glucose monitor and home +lood pressure monitor to track her progress at home$ @a*s to implement self monitoring include the RI o Pro,iding reasoning for self&monitoring o .elping to identif* patterns o -ssisting with goal setting o %ele+ration of successes 8uestion B: Gamil* /eals, .olida*s, and Special Eccasions 't is important to remem+er that some foods that are consumed on special occasions might seem e"cessi,e during a normal meal$ Rich foods that are high in fat and sugar are often ser,ed with traditional holida* meals$ Balance and moderation are ke*$ .owe,er, famil* meals are a dail* occurrence and must +e strategicall* approached$ The RI ma* assist an indi,idual +*2: o Asta+lishing a colla+orati,e relationship with the client$ 'n,ol,e the client in the goal setting process$ o 'dentif*ing famil*/communit* support$ o -ssisting clients in de,eloping asserti,eness skills$ o Otili7e modeling, skill training, respondent and operant conditioning o %onducting famil* education in a group$ Iiscuss health* eating for teenagers and reasons for eating healthfull*$ o Ancouraging famil* in,ol,ement in their lo,ed one4s transition 8uestion 1): PAS Statement, /onitoring, and A,aluation

Baranowski, B

PAS: E,erweight RT e"cessi,e energ* intake, food and nutrition related knowledge deficit, and not read* for diet/lifest*le change -AB higher than standard B/', higher than standard waist circumference, o,erconsumption of energ*&dense food and +e,erages, histor* of familial o+esit*, and conditions associated with meta+olic s*ndrome

The -cadem* of Iietetics and utrition( recommends 2&# follow up ,isits of ()& #) minutes each to impro,e lipid profile, weight status, and other /etS risk factors$ 'f a large num+er of therapeutic lifest*le changes 1TJ%2 need to +e made, or if the indi,idual is not moti,ated, as in this case, the num+er and duration of ,isits for / T will need to +e greater$ 'ncreasing the num+er of ,isits and time length will an RI can lead to impro,ed health outcomes o,erall$ Iata that should +e monitored at each ,isit include: waist circumference, .IJ, TH, weight, fasting glucose, using point of care testing for added con,enience$ 'n addition, the patient4s +eliefs and attitudes should +e re,iewed, as well as her progress using the Stages of %hange model$

-t each session, client and RI re,iew goals, which include weight loss of L & 1 l+$ per week, for a # month weight loss of 2(&2?l+s$ total$ This will take the client from 1>?l+s$ and a B/' of 2?$> to 1=)&1==l+s, and a B/' of 20&2=$ This will +e achie,ed +* following a 1,=))kcal menu plan similar to the fi,e da* plan that follows$ B* achie,ing these goals, the client will reduce the risk factors for /etS, and thus her predisposition for heart disease, dia+etes, and premature mortalit*$

Baranowski, 1) Reference Jist 1$ Amer* AP$ Clinical Case Studies for the Nutrition Care Process$ Philadelphia, P-: Qones R Bartlett Jearning! 2)12$ 2$ International Dietetics & Nutrition Terminology (IDNT) Reference Manual Standardized anguage for the Nutrition Care Process$ %hicago, 'J: -cadem* of utrition and Iietetics: 1022)1($ ($ elms /, Sucher SP, Jace* S, Roth SJ$ Nutrition Thera!y & Patho!hysiology$ Belmont, %-: %engage! 1222)11$ 0$ Ta5nik %S, Qoglekar %U, Pandit - , et al$ .igher Effspring Birth @eight Predicts the /eta+olic S*ndrome in /others +ut not in Gathers ? Tears -fter Ieli,er*$ Dia"etes$ 2))(! =2: 2)B)&2)B#$ =$ Iietitians of %anada$ http://www$eatracker$ca$ -ccessed Ecto+er 12, 2)1($