Lifestyle medicine diagnosis An appropriate beginning would be to assess the body measurements, co morbidities tests, genetic influences, diet,

lifestyle and other factors (individual characteristics for Jill). An understanding of patients religion, traditions and values in life can help to understand her specific individual characteristics. Genetic predisposition can influence the amount and rate at which weight is gained and lost, knowing the family history will also help. The next step would be to assess Jills previous weight loss attempts, past history events that could have influenced her stress and hypertension (evident from her BP level), weight gain (evident from her measurements such as BMI, WC ) She should be asked if she feels increased anxiety or other psychiatric disorders which may affect her physical or emotional balance and prevent her from improving her lifestyle; and if she has any physical limitations. What is/are the main (lifestyle-related) problem(s) with this patient? Waist circumference is measure of abdominal fat and in Jills case it is 90 (cut offs for Caucasian women < 88 cm), marking Jill as borderline obese. (Arden et al, 2004) She is prone to other co-morbidities associated with obesity. The major problem is hypertension (BP of 140/100 indicate stage 2 hypertension as the diastolic BP is very high). Jill also mentioned sleep disturbance as her current problem. At present, stress seems to be one of the prominent factors that may have caused weight gain in Jill. There generally are metabolic factors associated with stress and in addition stress can affect peoples eating habits. (Steele, 2010) The results and measurements together indicate the risks of metabolic syndrome (Raised BP, glucose and lipids) which increases her risk of CVD. It also seems that Jill is not aware of the harms from diabetes or obesity/ extra weight. Her father and mother fortunately had no obvious health problems, despite one parent diabetic (father) and mother overweight. This may have influenced Jill negatively that being overweight is not related to disease and she has not even known the harmful side of diabetes (her fasting blood sugar is raised but she does not seems worried) There is a definite need to control the hypertension with diet, exercise and medications to avoid further degeneration of health. The stress may intensify the risks for illness such as coronary heart disease, hypertension and noninsulin dependent diabetes. This is particularly

serious with more body weight, given the largely linear relationship between body weight and illness. What motivational theory would you use? Why? Banduras theory of self-efficacy can be used to increase self-efficacy of Jill with techniques like motivation interview and behaviour therapy. These are required for Jill to help her adapt to a new lifestyle and change attitude towards diet and exercise. Jill can be motivated by helping her identify and accept the dissonance between her present behaviours and the goals which she considers important for herself. A clinician must first develop a close therapeutic relationship using active listening skills, express empathy, warmth and then provide her appropriate feedback for the important goals of her life e.g., healthy and fit life to enjoy her married life, staying healthy to be able to take care of kids. During discussions, any conflict has to be avoided otherwise Jill will never open up and may develop defence mechanisms. Imposition of values, beliefs and opinions on weight loss also do not work out well, rather guiding Jill to the right direction is important so that she develops the right set of beliefs and feels intrinsically motivated for change. Thus, strategies to be employed should assist the patient to become empowered through a feeling of increased self-efficacy.

Motivational diagnosis:
Development of clinical intervention based on motivational principles can be used to target Jills readiness, willingness and ability to alter behaviour.
Stage of change: How ready, willing and able is this patient to change

The stage of change is contemplation as she is willing and she does not feels she is able to make changes. The high level of readiness is there in the context of a supportive family. Family support is a key to effective motivation and helps apply motivational strategies specific for each individual. (Mackerras, 2009) Jill is worried about her increased stress and sleep problem and it is definitely important for her to treat this. The key goal while dealing with a contemplator is to establish a good rapport with the client. This helps to heighten the client's self-awareness and increases his/her acceptance of the fact that a problem exists. In contemplation, the focus on the pros of behaviour change is achieved through encouraging the client to evaluate his/her options and consider the positive implications of change. In the action stage, attention needs to be focused on supporting the acquisition and practice of new

skills. This ways Jill can easily reach the next stages (prepare and act) of change, and then manageable short-term goals can be designed around behaviour change.
Barriers

Any injury or physical handicap or some sort of doubts/ scares in the mind can be barriers to change. In Jills case, the time she needs to take care of the kids is one of the barriers that can be taken care with her husbands support. The stress / hypertension are other barriers which need treatment before making other lifestyle changes to loose weight. It will be also good to identify if there are any limitations that may cause pain while targeting a lifestyle change.
Triggers

Jill is ready / motivated for behavioural changes and the support from her husband can be a real trigger. A real change can be triggered if she can be motivated that the challenges, pain and time taken in staying the same are greater than the pain and challenges involved in the change. A trigger that may not be as obvious is a health condition that the patient is unable to understand or communicate. Discussion of a happy family or a part time job that may give Jill more independence and opportunities to meet and greet people may also trigger her for a change.
Other factors influencing set to respond

Counselling will help to identify deep causes of behavioural intransigence (inflexibility) or focus on eating and exercise behaviours based on the notion that because they are learned they can be modified. (Garry, 2008) She can be advised to engage in some creative tasks or may be join a part time job to keep her busy. This will help her to break away from anxiety and stress. There are no obvious reasons for her anxiety and problems with sleep, however obesity can be a prominent factor. She can be offered exercise classes and if she feels too self-conscious (or cannot join with family tasks) to take these classes, she can also be advised for using an exercise video at home. Motivational tool(s)/Behavioural principles There is an energy imbalance from energy intake without inadequate energy expenditure, this needs dietary management and increased physical work. Jill needs a mentor to motivate her towards next stages of change (preparation and action). Jills husband can be an influencer and support her in the change by motivating her to engage in some external activities (sports, music, work, cooking) and reduce the emptiness that may have resulted from no work/job. It would be easy to motivate her for a change which would be beneficial for her growing kids.

A specially designed physical exercise programs for Jill would be very helpful. She can be referred to an exercise physiologist for informative discussion of the benefit of the customised program according to Jills abilities. It seems that she does not goes out much as she does not works and any sort of recreational activities will increase her physical movement and likely to decrease her stress. Recreational activities enhance adherence rates in comparison with aerobic or strength-based interventions (Dishman & Buckworth, 1996). Kilpatrick, Hebert, & Bartholomew (2005) in their study on women suggest that the recreational forms of physical activity in general, are more enjoyable in and of themselves than physical exercise and are linked more closely to the desired motivations to participate Jill can choose any sports what she likes or may be a dance program or a meditation session to keep her busy and happy and get away from depression and mental stress. In the approach method of motivation, the individual may choose to exercise more, realizing that burning extra calories will result in weight loss. As she is typically anxious, she is also likely to engage in avoidant behaviour and needs to be guided with a strategy for primordial prevention. Jill is therefore advised for avoiding energy dense foods simultaneously putting emphasis on the therapeutic benefits of interventions with improved diet and activity. A guide from a nutritionist can be provided to Jill so that she can learn to include variety of foods, in moderate amounts can assess the quantity of intake relative to her energy expenditure (physical activity). Applying the trans-theoretical model of change to the MI technique, Jill can be motivated by helping her identify and accept the dissonance between his/her present behaviour and the goals which she considers important. A clinician should listen to Jill actively, express empathy, warmth and then provide her appropriate feedback for the important goals of her life (e.g., healthy and fit life to enjoy her married life, staying healthy to be able to take care of kids) The role of context like family and kids is important because the key to effective motivation is to apply motivational strategies to the context of each individual. It is important to move Jill from extrinsic to intrinsic motivation. Jill can set achievable weight loss goals with a commitment (she is already motivated and possesses high selfefficacy). Jill is not working so she can engage in planning some new recipes for meals that are low in carbs and Glycemic index, still taste good. She can try a variety of foods corresponding to low calories and maintain a regular exercise schedule. She should measure her weekly progress (weight loss) which would bring her an idea of what she can achieve.

She should discuss the progress with her GP/ instructor/ nutritionist for a feedback and need to monitor her weight loss. Maintenance The changes beneficial for her health and well-being can be designed progressively. Jill can be motivated for changes that suit her interests and wishes e.g., start a professional career, part time job, joining a gym, joining a community club, engage in gardening or working from home. This will unlock her potential to a stage of happiness and get away from depression. Individual education and skills are likely to contribute to weight loss. Motivational and supportive counselling is essential to help Jill to not only start her program, but to maintain the results in the longer term (increase confidence, self-esteem and mental well-being). At this stage, regular counselling sessions can be planned and work out positive plans for her as she progresses with her lifestyle changes. Jill would need to be motivated regularly in all sessions so that she is persistent in her efforts and does not go off the track.

REFERENCES
Dishman, R. K., and J. Buckworth. (1996). Increasing physical activity: A quantitative synthesis. Med Sci Sports Exer 28(2), pp: 70619. Accessed online from Ebscohost Database Kilpatrick, M., E. Hebert, and J. Bartholomew. (2005) College students motivation for physical activity: Differentiating mens and womens motives for sport participation and exercise. J Am Coll Health, 54(2) pp: 8794. Accessed online from Ebscohost Database Steele, W. (2010) Motivational Principles Accessed online from www.findarticles.com Mackerras, D. (2009) Overweight and obesity in adults. Accessed online from http://www.carpa.org.au/Ref%20Manual%204th%20Ed/Chronic%20disease/O verweight_obesity_adults.pdf