METABOLICALLY HEALTHY OBESE

Nutrition Education Counseling Project

Metabolically Healthy Obese
DFM 655
Lisa Marquand and Tammy A. Keighran
12/6/2015

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Obesity has become a major concern of the United States population. A person diagnosed
with obesity typically has a body mass index (BMI) between 30-39.9. The Journal of American
Medical Association reported that more than one-third of the population is obese, with non-latino
blacks and latinos having the highest age-adjusted rates of obesity (Ogden et al, 2014). People
within this population may experience unhealthy metabolic changes, such as high blood pressure,
high cholesterol, and insulin resistance leading to hyperglycemia (Skerrett, 2013). There are also
cases in which obese people do not show any of these unhealthy characteristics commonly
associated with obesity; this condition is known as metabolically healthy obese.
One such patient is Tammy Arellano Keighran. She is a Mexican-American thirty-one
year old female. She is five feet and four inches (163 cm) tall and weighs one hundred and
seventy-five pounds (80 kg). Her body mass index (BMI) is 30, and she is therefore
characterized as obese. At her last physical examination her doctored ordered routine blood
work, prompted by her steady weight gain; all the results from the tests were normal. The blood
test results included: blood pressure (120/80), cholesterol (190 mg/dL), Hemoglobin A1c (5%),
and glucose (fasting: 100 mg/dL).
Tammys family health history includes incidences of diabetes, heart disease, high
cholesterol, and high blood pressure; her mother and father specifically suffer from type 2
diabetes and high blood pressure respectively. Tammy enjoys walking but hates other forms of
exercise explaining, Its boring. However, she is physically active due to her line of work.
Tammy is employed as a chef and works 60-80 hours a week, and sleeps 4-6 hours a night. She
is most interested in increasing her physical activity level specifically to lose weight.
The initial phase of the counseling interview is the involving phase. In this phase the
counselor sets the stage for the session. It is known as the relationship-building phase because

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client or counselor have either recently met or have never met and it is an opportunity for the
participants to get to know each other a little better. Some activities included in the involving
phase include a greeting, small talk, and an effort to establish comfort (Bauer, et al, 2012).
The purpose of the involving phase is to create a comfortable and safe atmosphere. It can
be difficult for a client or patient to see a counselor if they have been recently diagnosed with an
illness, if they are experiencing relapse in the stages of change, or if it is their first visit with a
counselor. The counselor should make a formal introduction to let the client know the
counselors credentials and education. In practice, one such introduction would be, Hello Mrs.
Smith, my name is Ms. Q. I am a registered dietitian and I specialize in diabetes education. The
client should feel like they are going to be helped, and that the counselor is qualified to do so.
An essential part of the involving phase is finding out exactly what the client wants to
achieve from counseling; sometimes developing long-term goals is desired, and sometimes, just
to get out of the office is the goal. It is the counselors responsibility to facilitate the session in
such a way to keep it client-centered and to allow the client to discover his or her own goals and
to respect the clients decisions, even if the client decides not to change at all. Regardless of the
clients readiness or willingness to change, the counselor can still inform the client with
appropriate information.
In order to keep the session going, an agenda must be established and communicated in
the involving phase. Adults in particular, like to know exactly what is going to happen, how long
it is going to take, and how much involvement is required. The counselor will use their judgment
based on the developed rapport with the client and base the agenda on the response of the client.
In this particular counseling session, the client was ready to change and therefore, the client was

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informed of possible goal development in the beginning and encouraged to pursue goals at the
end.
The exploration and education phase is the next phase of the counseling session. In this
phase the counselor is the educator and facilitates the client through self-exploration (Bauer, et
al, 2012). The counselor must allow the client to be the one to discover or uncover problems in
their own life (Miller, 2002). By doing so, that empowers the client to make decisions based on
self-determined ideas and plans. It is this second phase that verbal and nonverbal cues begin to
surface.
In the counseling session, there were significant nonverbal cues displayed by the client.
When talking about when the clients doctor called her obese, the client crossed legs and crossed
arms and leaned back in the chair attempting to get far away from the counselor. However, the
counselor, sensing the clients uneasiness leaned forward in the chair and empathized with the
client, therefore creating a sense of safety for the client. Later in the session, the client is
uncrossed and leaning forward (was written in script cues), possibly indicating interest in the
topic being counseled, and feeling more at ease.
In an effort to determine the clients readiness to make a change the tool that was used by
the counselor in the exploration and education phase was the 1-10 scale of ability and selfefficacy. The client therefore must think about how ready he or she is to actually make a change
and how confident he or she is to succeed. In the counseling session, the counselor first asks, on
a scale of 1 to 10, one being not ready at all and 10 being ready to change, how ready are you to
make these changes? to which the client answered that she was at an 8. Once the client has this
number, in order to further assess the clients readiness to change, and to allow the client to think
about that it means to be an 8 on the scale, the counselor asked, Why are you an 8 and not a 9?

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thus eliciting a response about perceived barriers and perceived risk. In this particular
counseling session, the client is ready to change, but understands that change can be difficult.
The resolving phase of the counseling session begins when the counselor initiates a
discussion about the current physical activity the patient enjoys. The counselor references the
client assessment questionnaire (CAQ) that was filled out previous to the counseling session,
which states the client is okay with walking. In order to uncover any other potential activities the
client may enjoy, the counselor asks an open-ended question, Have there been any activities you
have enjoyed in the past? in which the client reveals she enjoys tap dancing. The client seems a
little reluctant about tap dancing again, and the counselor discovers that time is the clients main
barrier.
In discovering the clients main barrier to incorporate more physical activity, the
counselor is able to help the client consider ways to make time. The client comes up with the
idea to have somebody relieve her at work so that she may participate in a tap dance class two
times per week. The counselor shows affirmation for this activity by telling the client that it
would be a good start to incorporate exercise into her lifestyle. At this point, the counselor is
almost positive that the client is ready to change. The counselor then uses the scale tool to
determine what readiness level of change the client is in, which reveals the client is a level 3:
ready to change. According to the transtheoretical model, the client is in the preparation phase
based on her motivation and intent to change by signing up for dances classes within the next
week (Bauer, et al, 2012).
The closing phase begins with the counselor praising the clients initiative to make
changes in her lifestyle. The counselor gives a brief overview of the counseling session and
stated the primary focus of the session. In order to facilitate further positive lifestyle changes, the

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counselor assigns the client with the task to keep a food log for 3 days before the next counseling
session. To get confirmation of the clients action plan, the counselor asks the client to tell her
what plan she has made for herself. The counselor reinforces the clients self-efficacy when she
tells her that the she has made good commitments for herself. The counselor shows her support
for the client by making a commitment to check with her in a couple days to make sure she is on
track. The next meeting is set for the following week to address the clients concern for her
eating habits.
This counseling project shows the challenges of both the client and counselor in a single
counseling session. The scenario we created gives an example of one of the biggest challenges
many people face while trying to incorporate healthy behaviors into their daily life: time. The
CAQ was used in creating the clients character. This is a helpful tool for the counselor as it gives
a brief background of the client, which can help save some time in short counseling sessions.
There are other tools that may be utilized when preparing for and conducting counseling
sessions. The counselor uses a scale tool during the session. This tool helps the counselor gage
the clients readiness to change. It is also helps to uncover any challenges the client may have, as
well as motivate the client to be at a higher level of readiness to change.
Although this counseling session was under ten minutes, we were able to successfully
move through all four phases of the counseling session. The introductory phase began with a
warm welcome, followed by rapport development between client and counselor. The
exploration/education phase was facilitated by the counselor, and the client was given the
opportunity to develop and express ideas for behavior change. The counselor makes a transition
to the resolving phase, in which she is able to help guide the client in making a commitment to a
lifestyle change that was created by the client. Once the client is able to make this commitment,

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the counselor briefly sums up the session, but asks the client to summarize the changes in order
to help solidify the commitment the client has made.
By appropriately directing and facilitating the client through phases of the counseling
session, the client is empowered to make a behavior change. With the use of various tools, the
counselor is able to conduct a counseling session in a short amount of time. This project was a
valuable learning experience as it helped to understand the amount of research and work
necessary for a successful counseling session.

References

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Bauer, K., Liou, D., & Sokolik, C. (2012). Nutrition counseling and education skill development
(Third ed.). Belmont, CA: Wadsworth, Cengage Learning.
Ogden, C., Carroll, M., Kit, B., and Flegal, K. (February, 2014). Prevalence of childhood and
adult obesity in the United States, 2011-2012. JAMA 311(8): 806-814.
doi: 10.1001/jama.2014.732.
Miller WR, Rollnick S (2002) Motivational interviewing, preparing people to
change addictive behavior (The Guildford Press, New York).
Skerret, P. (September, 2013). Overwiehgt and healthy: the concept of metabolically healthy
Obesity. Harvard health publiactions. Retrieved December 5, 2015 from
http://www.health.harvard.edu/blog/overweight-and-healthy-the-concept-ofmetabolically-healthy-obesity-201309246697

Appendices
1. Questionnaire

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2.
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5.

Script
Any tools used
LMF 7.5 (p.415) - leave blank
rubric